Nokea
The nurse is assessing a client with a history of migraines. Which of the following symptoms would the nurse expect the client to report?
- A. Bilateral dull headache.
- B. Photophobia and nausea.
- C. Constant daily headache.
- D. Pain relieved by physical activity.
Correct Answer: B
Rationale: Migraines typically cause unilateral throbbing pain with photophobia and nausea due to neurological sensitivity. Bilateral dull pain (A) suggests tension headache, constant pain (C) indicates chronic headache, and activity (D) worsens migraines.
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Following Nitroglycerin patch application
An expected outcome experienced by the client would be one of the following:
- A. Elevated blood pressure
- B. Tachycardia
- C. Tingling sensation
- D. Increased urine output
Correct Answer: B
Rationale: Nitroglycerin may cause reflex tachycardia as a compensatory response to vasodilation.
A woman has just started receiving external radiation therapy. When the nurse enters the client's room, she notes that the client is scrubbing the area vigorously with soap and water. When asked about her actions, the woman replies that she is trying to get rid of the ugly purple marks. What is the best action for the nurse at this time?
- A. Explain that the purple marks must stay on her because they tell the doctors where to beam the radiation
- B. Suggest that alcohol will make it easier to remove the marks
- C. Say, 'You feel the marks are ugly.'
- D. Ask her if she checked with her physician before trying to remove the purple marks
Correct Answer: A
Rationale: Radiation marks guide precise targeting; explaining their necessity prevents removal and ensures effective treatment.
Physical findings commonly seen in hypothyroidism include:
Coarse hair, thin brittle nails
- A. Malnourished appearance, alopecia
- B. Tachycardia, hyperreflexia
- C. Confusion, stupor
Correct Answer: A
Rationale: Coarse hair and thin brittle nails are classic signs of hypothyroidism due to decreased metabolic rate.
Order: Vancomycin HCl 1 g in 250 mL DW IVPB, infuse in 90 min. Calculate the flow rate in drops per minute. The drop factor is 20 gtt/mL.
- A. 56 gtt/min
- B. 67 gtt/min
- C. 30 gtt/min
- D. 31 gtt/min
Correct Answer: A
Rationale: 250 mL ÷ 90 min = 2.777 mL/min. 2.777 mL/min × 20 gtt/mL = 55.56 gtt/min, rounded to 56 gtt/min. Other options are incorrect.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (B), increased vaginal discharge (C), and diaphragmatic pressure (D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.