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The nurse is reinforcing teaching to a support group for partners of military veterans who have posttraumatic stress disorder (PTSD). The nurse explains that most clients with PTSD experience which symptoms?
- A. Auditory hallucinations and feelings of paranoia
- B. Excessive need for admiration and inflated self-importance
- C. Increased energy levels and euphoric mood
- D. Reliving the event and feeling detached from others
Correct Answer: D
Rationale: PTSD is characterized by reliving traumatic events and detachment (avoidance). Other options describe different disorders.
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The nurse is assisting with community health screening. Which of the following clients is the priority to refer for further evaluation?
- A. client with a random blood glucose of 139 mg/dL (7.1 mmol/L)
- B. client with shiny, hairless legs that are cool to the touch
- C. client who is an athlete with a heart rate of 50/min
- D. client with a blood pressure of 129/79 mm Hg
Correct Answer: B
Rationale: Shiny, hairless legs that are cool to the touch suggest peripheral artery disease, a serious condition requiring urgent evaluation. A is within normal glucose range (71-200 mg/dL). C is normal for an athlete. D indicates prehypertension, which is less urgent than vascular disease.
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
The client has a cast applied following a fracture of the femur. The doctor tells the nurse to petal the cast. The nurse is aware that he intends for her to:
- A. Cut the cast down both sides.
- B. Cut a window in the cast.
- C. Cover the edges with cast batting.
- D. Cut the cast down one side.
Correct Answer: C
Rationale: Petaling a cast involves covering the rough edges with adhesive tape or cast batting to prevent skin irritation. Cutting the cast or creating a window is a different procedure.
The nurse is caring for a client born at 42 weeks gestation. Which of the following potential clinical findings should the nurse anticipate for a postterm newborn? Select all that apply.
- A. Deep plantar creases
- B. Dry, cracked, peeling skin
- C. Lanugo on the extremities
- D. Long fingernails and scalp hair
- E. Minimal or absent vernix
Correct Answer: A,B,D,E
Rationale: Postterm newborns often have deep plantar creases, dry/peeling skin, long nails/hair, and minimal vernix due to prolonged gestation. Lanugo is more common in preterm infants.
The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? Select all that apply.
- A. Commercial fruit juice
- B. Flavored club soda
- C. Fresh vegetable juice
- D. Sports beverages
- E. Unsweetened tea
Correct Answer: B,C,E
Rationale: Flavored club soda, fresh vegetable juice, and unsweetened tea are low-calorie, healthier alternatives to cola. Fruit juice and sports drinks are high in sugar.