Nokea
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
You may also like to solve these questions
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following statements by the client indicates a need for further teaching?
- A. I should use this medication at bedtime.
- B. I should report eye pain to my doctor.
- C. I should avoid rubbing my eyes after using it.
- D. I should stop this medication if my vision improves.
Correct Answer: D
Rationale: Stopping latanoprost when vision improves is incorrect, as glaucoma requires lifelong treatment to prevent optic nerve damage. Options A, B, and C are correct: bedtime dosing is standard, eye pain may indicate complications, and avoiding rubbing prevents irritation.
Which of the following findings distinguishes a hydrocele from an inguinal hernia?
- A. The swelling cannot be reduced and is translucent.
- B. The swelling cannot be reduced and is opaque.
- C. The swelling can be reduced and is translucent.
- D. The swelling can be reduced and is opaque.
Correct Answer: A
Rationale: A hydrocele is non-reducible, translucent swelling due to fluid around the testis, unlike an inguinal hernia, which is often reducible and opaque.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.
A client is scheduled for a myelogram at the outpatient clinic.
Which of the following statements, if made by the nurse, correctly describes a myelogram?
- A. The Test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown.'
- B. The Test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk.'
- C. The Test involves a lumbar puncture with injection of contrast medium, allowing accettare visualization of the vertebral canal.'
- D. The Test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a myelogram. (1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct-contrast medium or air is injected into spinal subarachnoid space through a spinal puncture, identifies tumors, cysts, herniated vertebral discs (4) no such procedure