Nokea
The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.
- A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
- B. Increase your consumption of iron-rich foods like meat and dried fruit
- C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
- D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
- E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation
Correct Answer: A,B,D,E
Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.
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A client is admitted with pernicious anemia. The client reports all of the following. Which is most likely related to the admitting diagnosis?
- A. I often have diarrhea.'
- B. My tongue is more red and thick than usual.'
- C. I have little bruise-like spots on my arms and legs.'
- D. I have been running a fever for the last two days.'
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes a sore, red, beefy tongue. Diarrhea, bruising, or fever are less specific.
An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?
- A. The client moves the left crutch forward, then the right foot, then the right crutch, and finally the left foot.
- B. The client moves the left crutch and the right foot together, and then moves the right crutch and the left foot together.
- C. The client moves the left foot and the crutches forward while bearing weight on the right foot.
- D. The client bears weight on the left foot, and then moves the right foot and the crutches forward.
Correct Answer: A
Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.
The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia?
- A. 29-year-old client with new-onset influenza
- B. 40-year-old client who is a cyclist and is training for an upcoming race
- C. 65-year-old client with cellulitis of the right leg
- D. 72-year-old client with emphysema who is receiving prednisone
Correct Answer: D
Rationale: Prednisone increases blood glucose, but abrupt cessation or dose changes can cause hypoglycemia in type 1 diabetes due to insulin sensitivity. Influenza, exercise, and cellulitis pose risks, but prednisone’s metabolic impact is greatest.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.
The nurse is reinforcing teaching regarding home oxygen use for a client with emphysema who is using nasal cannula and portable oxygen tank. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I can continue to cook on my gas stove.
- B. I can use a humidifier if my nostrils feel dry.
- C. I need to keep a working fire extinguisher in my home.
- D. I should use a wool blanket on my bed instead of cotton.
- E. I can increase the oxygen flow rate whenever I feel short of breath.
Correct Answer: A,D,E
Rationale: Oxygen therapy is commonly prescribed to improve oxygenation for clients with (or at risk for) hypoxia (eg, emphysema) and to promote comfort in clients receiving palliative/hospice care. Clients requiring long-term oxygen therapy may be prescribed portable oxygen delivery (ie, home oxygen therapy) to allow increased independence in daily life.