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The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
- A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain.
- D. The client will record episodes of angina and self-management for one week.
Correct Answer: D
Rationale: Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions. Weekly monitoring, daily walking, and nitroglycerine use are important but do not directly address tracking angina episodes for management.
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Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]
The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.
- A. Preoccupation.
- B. Reexperience.
- C. Somatization.
- D. Disorganization.
Correct Answer: C
Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling, likely due to grief. Other options are less applicable.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)
- A. Measure the client's blood pressure in both arms.
- B. Screen for a family history of diabetes mellitus.
- C. Arrange for immediate transport to a medical facility.
- D. Advise the client to restrict fluids and keep feet elevated.
- E. Discuss the importance of a regular exercise program.
Correct Answer: A,B,E
Rationale: Measuring blood pressure assesses hypertension risk, screening for diabetes history addresses increased risk from obesity, and discussing exercise helps manage obesity-related risks. Immediate transport is not indicated, and fluid restriction/elevation is irrelevant without edema.
History and Physical
Initial vital signs:
Imaging Studies
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD).
She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client.
- A. Monitor cardiac status
- B. Educate on dialysis compliance
- C. Monitor vital signs
- D. Perform head-to-toe assessment
- E. Monitor heart rhythm
- F. Monitor fluid intake and output
- G. Monitor neuromuscular status
Correct Answer: A,B,C,D,E,F,G
Rationale: Monitoring cardiac status, vital signs, heart rhythm, fluid balance, and neuromuscular status, along with educating on dialysis compliance and low-potassium diet, are essential for managing ESRD and hyperkalemia. Transfer to telemetry is not indicated with stable vitals.