Nokea
The nurse is assessing a client with suspected Addison’s disease. Which of the following findings would the nurse expect?
- A. Weight gain and edema.
- B. Hyperpigmentation of the skin.
- C. Hypertension and tachycardia.
- D. Increased appetite and polyuria.
Correct Answer: B
Rationale: hyperpigmentation of the skin is a classic sign of Addison’s disease due to increased ACTH production
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The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
- A. Supine with legs abducted.
- B. High Fowler’s with legs extended.
- C. Side-lying on the unaffected side.
- D. Prone with legs adducted.
Correct Answer: D
Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement
A 19-year-old male has been experiencing vomiting and diarrhea for 3 days due to food poisoning. The nurse expects a urine specific gravity of
- A. 0.850.
- B. 1.005.
- C. 1.020.
- D. 1.041.
Correct Answer: D
Rationale: Dehydration from vomiting and diarrhea increases urine specific gravity (normal 1.005-1.030). 1.041 indicates concentrated urine due to fluid loss.
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.
A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. Bradycardia
- B. Decreased appetite
- C. Exophthalmos
- D. Weight gain
Correct Answer: C
Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.
A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.