Nokea
Laboratory results
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L) 126 mg/dL
(7.0 mmol/L)
The nurse in the outpatient clinic is caring for a 40-year-old client with acromegaly. Which of the following findings would be most important to report to the health care provider?
- A. Dark, leathery skin
- B. Fasting blood glucose level
- C. Presence of S3 and S4 heart sounds
- D. Reports of knee pain when walking
Correct Answer: C
Rationale: S3 and S4 heart sounds indicate heart failure, a serious complication of acromegaly due to cardiac hypertrophy, requiring urgent reporting. Skin changes, glucose levels, and knee pain are expected but less critical.
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The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.
A client asks, 'What should I do to prepare for a colonoscopy?' Which instructions should the nurse reinforce to correctly answer the client’s question? Select all that apply.
- A. No food or drink is allowed 8 hours prior to the test
- B. Prophylactic antibiotics are taken as prescribed
- C. Smoking must be avoided after midnight
- D. The day prior to the procedure your diet will be clear liquids
- E. You will drink polyethylene glycol as directed the day before
Correct Answer: A,D,E
Rationale: Fasting 8 hours, clear liquids the day before, and polyethylene glycol are standard colonoscopy preparations. Antibiotics are not routine, and smoking cessation is not specific to the procedure.
The nurse is reinforcing teaching about oral hydrocortisone for a client with newly diagnosed primary adrenal insufficiency (i.e., Addison disease). Which of the following information should the nurse reinforce? Select all that apply.
- A. Discontinue hydrocortisone if you have mood changes or disruptions in behavior
- B. Report even a low-grade fever to the health care provider immediately
- C. Report signs of hyperglycemia, including increased urine, hunger, and thirst
- D. The dose of hydrocortisone may need to be increased during times of illness or injury
- E. This medication should be taken on an empty stomach to enhance absorption
Correct Answer: B,C,D
Rationale: Reporting fever, hyperglycemia, and adjusting doses during illness are critical for Addison disease management. Hydrocortisone should not be stopped abruptly, and food enhances absorption.