Nokea
The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?
- A. reports of intermittent nausea
- B. crackles in the lung bases bilaterally
- C. 1+ pitting edema of the ankles and feet bilaterally
- D. blood pressure of 108/88 mm Hg and heart rate of 72/min
Correct Answer: B
Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.
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The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
The home health nurse is reviewing current medications with a client who has hypertension. Which of the following statements by the client would require follow-up?
- A. I take omeprazole daily to prevent heartburn.
- B. I regularly take ibuprofen for chronic low back pain.
- C. I occasionally take docusate sodium for constipation.
- D. I take hydrochlorothiazide daily to lower my blood pressure.
Correct Answer: B
Rationale: Ibuprofen can reduce the efficacy of antihypertensives and cause fluid retention, worsening hypertension. Omeprazole , docusate , and hydrochlorothiazide are unlikely to interfere with hypertension management.
Which one of the following symptoms is commonly reported in children with attention deficit hyperactive disorder?
- A. Difficulty sleeping at night
- B. Impulsivity
- C. Poor appetite
- D. Nonintentional tremor
Correct Answer: B
Rationale: Impulsivity is a hallmark symptom of ADHD, characterized by acting without forethought, often seen in children with the disorder.
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?
- A. Blood pressure
- B. Hematuria
- C. Peripheral edema
- D. Serum lipid levels
Correct Answer: A
Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.
A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?
- A. Encourage the parents to openly discuss the child's questions
- B. Notify the health care provider about the child's questions
- C. Remind the child that everyone is trying to help the child get better
- D. Tell the child to ask the parents the questions about death
Correct Answer: A
Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.