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The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
- A. Hyperpigmentation of the skin.
- B. Hypotension.
- C. Moon face and buffalo hump.
- D. Weight loss.
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.
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A client with newly diagnosed hypertension is prescribed enalapril (Vasotec). Which instruction should the nurse provide to the client?
- A. Increase your intake of potassium-rich foods.
- B. Report any persistent cough to your healthcare provider.
- C. Take the medication with a full meal.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: Report any persistent cough to your healthcare provider. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a side effect. This cough can be a sign of a serious condition called angioedema. Therefore, it is crucial for the client to report any cough to their healthcare provider promptly to assess and manage it.
Incorrect choices:
A: Increasing intake of potassium-rich foods is not necessary when taking enalapril, as it does not typically cause potassium imbalances.
C: Enalapril can be taken with or without food, so taking it with a full meal is not a specific instruction.
D: Avoiding grapefruit juice is typically recommended for medications metabolized by the CYP3A4 enzyme, which enalapril is not.
The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?
- A. Hemoglobin level of 12 g/dL.
- B. Platelet count of 150,000/mm3.
- C. White blood cell count of 2,000/mm3.
- D. Serum creatinine level of 1.0 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct Answer: B
Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence.
Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being.
Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship.
Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed.
Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.
A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
- A. Decreased libido is a common side effect of SSRIs and may improve over time.
- B. I will notify your healthcare provider to discuss possible medication changes.
- C. You should take your medication with food to reduce side effects.
- D. Increase your daily exercise to help manage this side effect.
Correct Answer: B
Rationale: The correct response is B: I will notify your healthcare provider to discuss possible medication changes. This is the best choice because decreased libido is a common side effect of SSRIs that can significantly impact the client's quality of life. Consulting the healthcare provider is crucial to explore alternative treatment options or adjustments to improve the client's symptoms. Choices A, C, and D do not address the underlying issue of decreased libido and are unlikely to provide effective solutions. Choice A only acknowledges the side effect without offering a proactive solution. Choice C is unrelated to the sexual side effect and may not address the client's concerns. Choice D suggests a general lifestyle change that may not directly address the medication side effect. Consulting the healthcare provider for medication adjustments is the most appropriate action to address this specific side effect.