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The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition?
- A. Epistaxis
- B. Dizziness
- C. Blurred vision
- D. A feeling of fullness in the head
Correct Answer: D
Rationale: A feeling of fullness in the head is more likely associated with a sinus condition than hypertension. Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, epistaxis, dizziness, blurred vision, lightheadedness, and vertigo. The client should be aware of these signs/symptoms and report them if they occur. The client should also be taught to self-monitor the blood pressure.
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The nurse is providing home care dietary instructions to a client who has been hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid to prevent recurrence?
- A. Chili
- B. Bagels
- C. Lentil soup
- D. Watermelon
Correct Answer: A
Rationale: Pancreatitis involves inflammation of the pancreas, and spicy foods like chili can stimulate pancreatic secretions, potentially triggering a recurrence. The client should eat small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates. Bagels, lentil soup, and watermelon are generally bland and acceptable.
A client is being discharged to home after prostatectomy for treatment of benign prostatic hyperplasia. Which point should the nurse plan to teach the client as part of the discharge teaching?
- A. Mowing the lawn is allowed after 1 week.
- B. Avoid lifting more than 50 pounds for 4 to 6 weeks after surgery.
- C. Drink at least 15 glasses of water a day to minimize clot formation.
- D. Notify the primary health care provider if fever, increased pain, or an inability to void occurs.
Correct Answer: D
Rationale: Notifying the primary health care provider about fever, increased pain, or inability to void is critical to detect complications like infection or urinary obstruction. Mowing the lawn is too strenuous too soon, lifting more than 20 pounds is prohibited, and 15 glasses of water daily is excessive; 6 to 8 glasses are sufficient.
The community health nurse teaches a group of females how to prevent pelvic inflammatory disease (PID). What instruction should the nurse include?
- A. To douche monthly
- B. To avoid unprotected intercourse
- C. To use only ultra-low dose oral contraceptive pills
- D. To consult with a gynecologist regarding the placement of an intrauterine device (IUD)
Correct Answer: B
Rationale: PID is an infection of the pelvis. The primary prevention of PID includes avoiding unprotected intercourse. Douching leads to a higher risk for PID. It is believed that high hormonal doses may decrease risk of PID, but ultra-low doses will not. The use of an IUD may also increase the risk for PID.
The nurse assesses cranial nerve XII in the client who sustained a stroke. Which action should the nurse ask the client to perform?
- A. Extend the arms.
- B. Extend the tongue.
- C. Turn the head toward the nurse's arm.
- D. Focus the eyes on an object held by the nurse.
Correct Answer: B
Rationale: Cranial nerve XII (hypoglossal) controls tongue movement, so extending the tongue tests its function. Other actions test different nerves or motor functions, not relevant to cranial nerve XII.
A mother brings her 6-month-old child to the clinic for a wellness checkup. The nurse anticipates that the health care provider will order which vaccinations for this client?
- A. DTaP and MMR
- B. Hib and varicella
- C. hepatitis B and DTaP
- D. hepatitis A and MMR
Correct Answer: C
Rationale: At 6 months, hepatitis B and DTaP are scheduled. MMR, varicella, and hepatitis A are given later (12-15 months).