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The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
- A. Weight loss
- B. Flat neck and hand veins
- C. An increase in blood pressure
- D. A decreased central venous pressure (CVP)
Correct Answer: C
Rationale: An increase in blood pressure is a common sign of fluid volume excess in clients with congestive heart failure due to the increased amount of fluid in the vascular system. Weight loss (Choice A) is not typically associated with fluid volume excess. Flat neck and hand veins (Choice B) are signs of fluid volume deficit, not excess. A decreased central venous pressure (CVP) (Choice D) is not expected in a client with fluid volume excess.
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A client with Cushing's syndrome has been prescribed a diet low in sodium. The nurse knows that the client should avoid which of the following foods?
- A. Bananas
- B. Spinach
- C. Processed meats
- D. Oatmeal
Correct Answer: C
Rationale: The correct answer is C: Processed meats. Clients with Cushing's syndrome who are on a low-sodium diet should avoid processed meats because they are typically high in sodium. Bananas, spinach, and oatmeal are generally low in sodium and can be included in a low-sodium diet. Bananas are a good source of potassium, spinach is rich in vitamins and minerals, and oatmeal is a healthy whole grain option. Therefore, choices A, B, and D are not the best options to avoid for a client with Cushing's syndrome following a low-sodium diet.
A client with type 2 DM is being taught about the importance of foot care. Which instruction should the nurse include?
- A. Wear comfortable shoes that allow air circulation.
- B. Walk barefoot whenever possible.
- C. Use a heating pad to warm your feet.
- D. Soak your feet in hot water every night.
Correct Answer: A
Rationale: The correct instruction for a client with type 2 diabetes mellitus (DM) regarding foot care is to wear comfortable shoes that allow air circulation. This recommendation helps prevent foot injuries and infections, which are common concerns for individuals with diabetes. Choice B, walking barefoot, can increase the risk of injuries and wounds due to reduced sensation in the feet often seen in diabetes. Choice C, using a heating pad, can lead to burns or skin damage if the temperature is not carefully monitored, making it an unsafe practice. Choice D, soaking feet in hot water every night, can also be harmful as it can cause burns and dry out the skin, leading to further complications for individuals with diabetes. Therefore, the most appropriate and safe advice is to wear comfortable shoes that promote air circulation to maintain foot health and prevent complications.
A client is diagnosed with hyperthyroidism. The nurse anticipates which of the following medications to be ordered?
- A. Levothyroxine
- B. Propylthiouracil
- C. Lithium
- D. Metoprolol
Correct Answer: B
Rationale: The correct answer is B: Propylthiouracil. Propylthiouracil is an antithyroid medication used to manage hyperthyroidism by inhibiting the synthesis of thyroid hormones. Levothyroxine (Choice A) is typically used to treat hypothyroidism, the opposite of hyperthyroidism. Lithium (Choice C) is not used to treat hyperthyroidism but is commonly used to manage bipolar disorder. Metoprolol (Choice D) is a beta-blocker that may be used to manage symptoms like tachycardia associated with hyperthyroidism, but it is not the primary treatment for the condition.
A client with type 2 DM is prescribed metformin (Glucophage). The nurse should include which instruction when teaching the client about this medication?
- A. Take the medication with meals.
- B. Take the medication on an empty stomach.
- C. Avoid taking the medication if you miss a meal.
- D. Take the medication before bedtime.
Correct Answer: A
Rationale: The correct instruction when taking metformin (Glucophage) is to take the medication with meals. Taking metformin with meals helps to reduce gastrointestinal side effects and improve absorption. Choice B is incorrect because taking metformin on an empty stomach can increase the risk of gastrointestinal side effects. Choice C is incorrect because missing a meal does not mean the medication should be avoided; the client should still take it with the next meal. Choice D is incorrect because there is no specific recommendation to take metformin before bedtime.
The healthcare provider is caring for a client with pheochromocytoma. Which of the following interventions should the healthcare provider implement?
- A. Administer beta-blockers to control blood pressure
- B. Encourage a high-sodium diet
- C. Monitor for signs of hyperglycemia
- D. Restrict fluid intake to prevent edema
Correct Answer: A
Rationale: The correct intervention for a client with pheochromocytoma is to administer beta-blockers to control blood pressure. Pheochromocytoma is a catecholamine-secreting tumor that can cause severe hypertension. Beta-blockers are used to block the effects of catecholamines and help control blood pressure in these clients. Encouraging a high-sodium diet (Choice B) would not be appropriate as it can worsen hypertension. Monitoring for signs of hyperglycemia (Choice C) is not directly related to managing pheochromocytoma. Restricting fluid intake (Choice D) may lead to dehydration and is not a recommended intervention for this condition.