Nokea
The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
- A. Weigh yourself daily.'
- B. Limit exercise to 10 minutes daily.'
- C. Increase sodium intake.'
- D. Take over-the-counter pain relievers as needed.'
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
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A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Myopia
- D. Amblyopia
Correct Answer: C
Rationale: Visual images are blurred and distorted. Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. These symptoms are classic for myopia. Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:
- A. There is no test to measure abnormal hemoglobin in newborns.
- B. Infants do not have insensible fluid loss before a year of age.
- C. Infants rarely have infections that would cause them to have a sickling crises.
- D. The presence of fetal hemoglobin protects the infant.
Correct Answer: D
Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.
A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
- A. Complaints of a headache
- B. Loss of superficial and deep tendon reflexes
- C. Complaints of shortness of breath
- D. Facial paralysis
Correct Answer: C
Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.
A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?
- A. Monitoring the client's vital signs
- B. Maintaining constant bladder irrigation
- C. Limiting fluid intake to 1000 mL per day
- D. Checking for post-operative bleeding
- E. Maintaining bed rest for 48 hours
Correct Answer: A, B, D
Rationale: Post-TURP care includes monitoring vital signs (A), constant bladder irrigation (B) to prevent clots, and checking for bleeding (D). Fluid intake is encouraged (C), and bed rest is typically 24 hours (E).
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:
- A. Gravida 3 para 1
- B. Gravida 3 para 2
- C. Gravida 2 para 1
- D. Gravida 2 para 2
Correct Answer: B
Rationale: Gravida=3 (current pregnancy), Para=2 (two births after 20 weeks).