Nokea
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure readings will be less than 160/90 mm Hg.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The client's daily blood pressure will be less than 140/80 mm Hg this month.
Correct Answer: D
Rationale: Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to reduce cardiovascular complications, including those contributing to blurred vision.
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The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Verify prescribed laboratory tests include prothrombin time and platelet count.
- D. Maintain elevated positioning of the dependent joints on affected side.
Correct Answer: A
Rationale: Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is essential for managing a suspected stroke, enabling time-sensitive interventions.
History and Physical
A 59-year-old male client presents to the clinic, reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work
Select the 3 dietary choices that are not part of the recommended diet for a client with gout.
- A. Garlic
- B. Liver
- C. Spinach
- D. Oatmeal
- E. Chicken
- F. Shrimp
- G. Lentil
Correct Answer: B,F
Rationale: Liver and shrimp are high in purines, which can exacerbate gout by increasing uric acid levels. Garlic, oatmeal, chicken, quinoa, oranges, spinach, and lentils are generally safe or have minimal impact on gout.
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. Symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous.
Correct Answer: A,B
Rationale: The client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise suggest that the client's asthma is not well-controlled, warranting immediate medical attention.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Muscle atrophy.
- B. Low grade fever.
- C. Joint pain.
- D. Hematuria.
Correct Answer: D
Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Restrict protein intake by limiting meats and other high protein foods.
- B. Increase intake of high fiber foods, such as bran cereal.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of potassium rich foods such as bananas or cantaloupe.
Correct Answer: A
Rationale: Restricting protein intake is often recommended for glomerulonephritis to reduce kidney workload and decrease proteinuria, slowing kidney damage progression.