Nokea
The nurse has just returned to the desk and has four phone messages to return.
- A. Which phone message should the nurse return first?
- B. A woman in her first trimester of pregnancy complaining of heartburn.
- C. A man complaining of heartburn that radiates to his jaw.
- D. A woman complaining of hot flashes and difficulty sleeping.
- E. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
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The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
- A. Dry mouth
- B. Weak muscles
- C. Sore throat
- D. Irritated nose
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
- A. My wife complains because I snore off and on all night.'
- B. I like to nap in the afternoon.'
- C. I wake up early every morning.'
- D. My muscles seem to jerk as I fall asleep.'
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.