Nokea
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?
- A. Hypertension.
- B. Diabetes mellitus.
- C. Inadequate lifestyle changes in diet and exercise.
- D. Increased risk of chronic illnesses.
Correct Answer: C
Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.
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When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?
- A. Participate in an exercise program for 6 weeks
- B. Obtain blood pressure daily for 2 weeks
- C. Increase dietary intake of omega-3 fatty acids
- D. Begin a low sodium diet immediately
Correct Answer: D
Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. How long has the client been taking the medication?
- B. Assess the client's dietary habits.
- C. Check for signs of infection.
- D. Evaluate the client's sleep pattern.
Correct Answer: A
Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.
When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?
- A. Leave a detailed message about the client's condition.
- B. Tell the receptionist to have the healthcare provider return the phone call.
- C. Call another healthcare provider.
- D. Document the attempt to call the healthcare provider.
Correct Answer: B
Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.
The healthcare provider is assessing a client who has a new arteriovenous fistula in the left arm for hemodialysis. Which finding requires immediate intervention?
- A. A thrill is palpable on the fistula.
- B. The client's arm is warm and red.
- C. The fistula has a bruit on auscultation.
- D. There is no bruit on auscultation.
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness in the client's arm suggest infection or thrombosis of the arteriovenous fistula, which requires immediate intervention to prevent complications. A thrill (A) is a normal finding in a functional arteriovenous fistula, indicating good blood flow. A bruit (C) is also a normal finding on auscultation of a functioning arteriovenous fistula, indicating proper blood flow. The absence of a bruit (D) may indicate a non-functioning fistula, which would need further evaluation but does not require immediate intervention as warmth and redness do.
The nurse is caring for a client with hyperthyroidism. Which assessment finding requires immediate intervention?
- A. Heart rate of 100 beats per minute.
- B. Blood pressure of 150/90 mm Hg.
- C. Respiratory rate of 24 breaths per minute.
- D. Weight loss of 5 pounds in one week.
Correct Answer: D
Rationale: Weight loss of 5 pounds in one week in a client with hyperthyroidism is concerning as it may indicate severe hypermetabolism, leading to potential complications such as cardiac arrhythmias, muscle weakness, and other metabolic disturbances. Rapid weight loss in hyperthyroidism indicates an accelerated metabolic rate and increased energy expenditure, which can be detrimental to the client's health. The other assessment findings (heart rate of 100 beats per minute, blood pressure of 150/90 mm Hg, respiratory rate of 24 breaths per minute) are commonly seen in clients with hyperthyroidism and may not necessarily require immediate intervention unless they are significantly outside the normal range or causing distress to the client.