Nokea
The nurse is working with a client who experiences orthostatic hypotension. Which suggestion would benefit the client?
- A. Sleep completely flat and do not use any pillows to prop your head.'
- B. Wear your support stockings when you sleep.'
- C. Take your blood pressure medicine immediately before trying to stand up.'
- D. Do not drink any liquids after 8 p.m.'
- E. None
- F. all the above
Correct Answer: E
Rationale: None of the options directly address orthostatic hypotension effectively. Support stockings during the day (not sleep), slow position changes, and adequate hydration are better strategies.
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The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to swelling of neck
- B. Anxiety-related changes in body image
- C. Altered nutrition, less than body requirements, related to difficulty in swallowing
- D. Risk for ineffective airway clearance related to pressure on the trachea
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.
- A. tetrahydrozoline (Tetryzoline)
- B. isotretinoin (Accutane)
- C. levonorgestrel (Levora)
- D. sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
Which information should be reported to the state Board of Nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past 3 days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Correct Answer: B
Rationale: Incorrect narcotic counts suggest potential diversion or mismanagement of controlled substances, which must be reported to the state Board of Nursing.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.