Nokea
The nurse is collecting data from a client with suspected panic disorder. Which of the following findings would be consistent with the condition?
- A. sweating
- B. dizziness
- C. compulsions
- D. heart palpitations
- E. shortness of breath
Correct Answer: A,B,D,E
Rationale: Panic disorder is characterized by sudden, intense fear accompanied by physical symptoms such as sweating (A), dizziness (B), heart palpitations (D), and shortness of breath (E). Compulsions (C) are associated with obsessive-compulsive disorder, not panic disorder.
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The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?
- A. I have a burning sensation when I urinate.
- B. I have been having some dribbling after I finish urinating.
- C. I missed 3 days of finasteride while on a trip last week.
- D. I was awakened 3 times last night by the need to urinate.
Correct Answer: A
Rationale: Burning on urination (A) suggests a urinary tract infection, requiring investigation. Dribbling (B), nocturia (D), and missing doses (C) are common with BPH or medication non-adherence but less urgent.
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
- A. Use ready-to-feed commercial infant formula
- B. Boil the tap water for 10 minutes prior to preparing the formula
- C. Let tap water run for 2 minutes before adding to concentrate
- D. Buy bottled water labeled 'lead free' to mix the formula
Correct Answer: C
Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.
Immediately following a cardiac catheterization, the client asks to go to the toilet. What is the best response by the nurse?
- A. Assist the client to the toilet
- B. Show the client where the toilet is and allow him/her to walk there if stable
- C. Assist the client to a bedside commode
- D. Assist the client onto a bedpan
Correct Answer: D
Rationale: Post-catheterization, bed rest is required to prevent bleeding at the insertion site; a bedpan maintains immobility.
A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?
- A. The client has difficulty moving his right arm.
- B. The client did not notice a nurse who was standing on his left side.
- C. The client is having difficulty swallowing.
- D. The client is having difficulty speaking.
Correct Answer: B
Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.
The nurse is providing home care to an elderly woman who had a cerebrovascular accident several weeks ago. All of the following need to be done. Which should the nurse plan to do first?
- A. Auscultate lung fields
- B. Hygienic care
- C. Assist with ambulation
- D. Range-of-motion (ROM) exercises
Correct Answer: A
Rationale: Auscultating lung fields assesses respiratory status, a priority post-CVA to detect complications like pneumonia or atelectasis. Hygienic care, ambulation, and ROM are secondary.