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The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
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A client with a history of prostate cancer is admitted with complaints of bone pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Bone pain in prostate cancer often indicates bone metastasis, so monitoring for metastasis is the priority.
Which complaint is frequently expressed by a client with macular degeneration?
- A. Problems with activities requiring focused vision such as sewing
- B. Severe eye and face pain accompanied by nausea and vomiting
- C. Seeing halos around lights
- D. Veil-like loss of vision
Correct Answer: A
Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.
A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.
Correct Answer: 21 pounds
Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.
The client is prescribed levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include?
- A. Take the medication at bedtime.'
- B. Report palpitations or chest pain.'
- C. Increase dietary fiber to prevent constipation.'
- D. Take the medication with meals.'
Correct Answer: B
Rationale: Levothyroxine can cause cardiac side effects like palpitations or chest pain, which should be reported. It is taken in the morning, fiber is not directly related, and food reduces absorption.
A client with a history of a stroke is being discharged. The nurse should teach the client to:
- A. Avoid all physical activity
- B. Use assistive devices as needed
- C. Limit social interactions
- D. Eat a high-sodium diet
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.