Nokea
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
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A client at the family planning clinic requests a prescription for oral contraceptives from the nurse who is performing an assessment. After reviewing the client's chart, the nurse determines that oral contraceptives are contraindicated because of which documented item? (Refer to chart.)
- A. Has renal calculi
- B. Blood pressure: 108 / 72mmHg
- C. Had thrombotic stroke at age 35 years
- D. Apical heart rate: 72 beats/min
Correct Answer: C
Rationale: Oral contraceptives are contraindicated in women with a history of thrombophlebitis and thromboembolic disorders; cardiovascular or cerebrovascular diseases (including stroke [brain attack]); any estrogendependent cancer or breast cancer, or benign or malignant liver tumors; impaired liver function; hypertension; or diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep vein thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors.
The community health nurse provides an educational session regarding the risk factors for cervical cancer to women in the local community. The nurse determines that further teaching is needed if a woman attending the session identifies which as a risk factor for this type of cancer?
- A. Smoking tobacco
- B. Single sex partner
- C. Early age of first intercourse
- D. Human papillomavirus (HPV) infection
Correct Answer: B
Rationale: Having a single sex partner is not a risk factor for cervical cancer. Some risk factors for cervical cancer include having multiple sexual partners or a partner who had multiple sexual partners, smoking tobacco, early age of first intercourse, and HPV infection.
The nurse is teaching dietary modifications to the client with hypertension. The nurse should instruct the client to eat which snack foods?
- A. Raw carrots
- B. Celery stalks
- C. Frozen pizza
- D. Cheese and crackers
- E. Canned tomato soup
Correct Answer: A,B
Rationale: Sodium should be avoided by the client with hypertension. Fresh fruits and vegetables such as carrots and celery are naturally lower in sodium. Hypertensive clients are also advised to keep fat intake to less than 30% of their total calories as part of prudent heart living. Each of the incorrect options contains high amounts of sodium, and frozen pizza and cheese and crackers are also likely to be higher in fat.
The nurse is instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
- A. Peak
- B. Onset
- C. Duration
- D. Anytime
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
A client's wife tells the nurse, 'I can't believe my husband has high blood pressure. He feels fine. What caused this?' The nurse's response should include which of the following? Select all that apply.
- A. One-third of people with high blood pressure are not aware of it.
- B. Clients over 50 years of age are at the highest risk of hypertension.
- C. Hypertension is more common in Hispanics and Native Americans.
- D. Hypertension is more prevalent in the southeastern United States.
- E. Your husband works at a desk job all day, so he does not get as much physical activity as he should.
Correct Answer: A,B,D,E
Rationale: Many are unaware of hypertension, age over 50 and sedentary lifestyle increase risk, and it's more prevalent in the Southeast. Hypertension is more common in African Americans, not Hispanics or Native Americans.