Nokea
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?
- A. Blurred vision.
- B. Shoulder pain.
- C. Abdominal pain.
- D. Rhinorrhea or otorrhea with halo sign.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A community health nurse is helping a group of nursing students plan a tertiary prevention program for a local community clinic that serves a majority Hispanic population. Which service project meets the requirement of a tertiary prevention program and would best serve this population?
- A. teach clients about recommended immunizations for children
- B. demonstrate foot care to a group of clients who have diabetes
- C. take blood pressures at a local shopping mall in the community
- D. instruct teens about prevention of sexually transmitted diseases
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?
- A. total cholesterol 190
- B. glycosylated hemoglobin of 7%
- C. B-type natriuretic peptide 550 pg/ml (more than 100 is bad)
- D. potassium 3.7
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a home health visit the nurse notices that an older male client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports that he cannot comfortably wear other shoes because his toenails get in the way. The nurse inspects the clients feet and finds long thick nails that curl down under some of the toes. Which action should the nurse take?
- A. demonstrate proper foot care to client and family
- B. have a home health aide assist client with hygiene weekly
- C. schedule an appointment for the client with podiatrist
- D. trim the clients toenails gradually over several visits
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.