Nokea
The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
- A. Cerebrovascular accidents (CVAs).
- B. Liver disease.
- C. Myocardial infarction.
- D. Pulmonary disease.
Correct Answer: A,C
Rationale: Hypertension increases the risk of cerebrovascular accidents (A) and myocardial infarction (C), as it damages blood vessels, leading to stroke or heart attack.
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What is the nurse's best action for a client with a migraine headache?
- A. Administer oxygen.
- B. Provide a quiet, dark environment.
- C. Encourage fluid restriction.
- D. Apply a warm compress.
Correct Answer: B
Rationale: A quiet, dark environment reduces stimuli that exacerbate migraine symptoms.
A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps:
- A. Slow progression of exophthalmos.
- B. Reduce the vascularity of the thyroid gland.
- C. Decrease the body's ability to store thyroxine.
- D. Increase the body's ability to excrete thyroxine.
Correct Answer: B
Rationale: SSKI reduces the vascularity of the thyroid gland, making surgery safer by decreasing the risk of bleeding. It does not primarily affect exophthalmos, thyroxine storage, or excretion.
A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?
- A. Discourage sitz baths because they promote bacterial growth.
- B. Apply zinc oxide ointment to the rectal area after each bowel movement to protect the skin.
- C. Apply a skin-barrier dressing daily to the rectal area to form a protective barrier.
- D. Clean the rectal area with unscented soap and water after each bowel movement, rinse well, and pat dry.
Correct Answer: D
Rationale: Cleaning with unscented soap and water, rinsing, and patting dry after each bowel movement prevents skin breakdown and maintains integrity in clients with diarrhea.
Which of the following describes decerebrate posturing?
- A. Internal rotation and adduction of arms with the excess, wrists, and fingers.
- B. Back hunched with the position of all four extremities with supination of arms and plantar flexion of feet.
- C. Supination of arms, dorsiflexion of the feet.
- D. Back arched, rigid extension of all four extremities.
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
- A. Decreased pain
- B. Increased urinary output
- C. Decreased blood pressure
- D. Decreased temperature
- E. Increased muscle coordination
Correct Answer: A,D
Rationale: Ketorolac, an NSAID, reduces pain and inflammation, which can lower temperature in febrile clients. It does not directly affect urinary output, blood pressure, or muscle coordination.