Nokea
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. heart rate less than 60/min
- B. moderate to high urine ketones
- C. increased serum potassium level
- D. blood pressure greater than 140/90 mm Hg
Correct Answer: B
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.
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The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?
- A. The cholesterol level is slightly high, but exercise and a low-fat diet should reduce it to normal.
- B. The cholesterol level is below normal levels, but this is good.
- C. The cholesterol level is high. The neighbor should talk with the physician about ways to lower it.
- D. The cholesterol is within normal limits.
Correct Answer: C
Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.
The nurse is caring for an older adult client who has experienced recent multiple falls and weight loss. The client lives with an adult child, but the nurse is questioning the safety of the home. Which of the following interdisciplinary team members would be most appropriate for the nurse to consult?
- A. adult protective services
- B. physical therapist
- C. social worker
- D. physician
Correct Answer: C
Rationale: A social worker can assess the home environment, coordinate resources for safety modifications, and address caregiving concerns, making them the most appropriate consult for home safety evaluation.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply.
- A. Not taking tetracycline with dairy products
- B. Taking tetracycline at bedtime
- C. Taking tetracycline with food
- D. Using additional contraceptive techniques
- E. Using sunblock
Correct Answer: A,D,E
Rationale: Tetracycline binds to calcium in dairy, reducing absorption. It can reduce oral contraceptive efficacy, requiring backup methods. Photosensitivity necessitates sunblock. Taking with food or at bedtime is acceptable but not critical teaching.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
- A. Offer small meals of high calorie soft food
- B. Assist the client to sit in a chair for meals
- C. Provide additional servings of fruits and raw vegetables
- D. Encourage the client to eat fish, liver and chicken
Correct Answer: A
Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.