Nokea
The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:
- A. Take antihypertensives as prescribed
- B. Skip doses if feeling better
- C. Increase sodium intake
- D. Avoid exercise
Correct Answer: A
Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.
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The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
- A. Fetal bleeding
- B. Maternal hemorrhage
- C. Preterm labor
- D. Fetal macrosomia
Correct Answer: A
Rationale: Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. A 3+ patellar tendon reflex
- B. Respirations of 12 breaths/min
- C. Urine output of 40 mL/hr
- D. A 2+ proteinuria value
Correct Answer: B
Rationale: MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing.
Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
- A. Extreme weight loss
- B. Presence of lanugo over body
- C. Erosion of tooth enamel
- D. Muscle wasting
Correct Answer: C
Rationale: Bulimia nervosa involves recurrent binge eating followed by purging, often through vomiting, which exposes teeth to stomach acid, leading to enamel erosion. Extreme weight loss and lanugo are more characteristic of anorexia nervosa, and muscle wasting is not a primary feature of bulimia.
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?
- A. Do you get along well with your family?'
- B. Do you communicate with your parents?'
- C. You don't hate your family, do you?'
- D. What is it like between you and your family?'
Correct Answer: D
Rationale: (A, B) This statement can be answered with a simple yes or no. This statement is asked in a negative manner and therefore has a negative connotation. This statement is open ended and positively stated.