Nokea
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Self-discipline is required to control caloric intake throughout the pregnancy
- D. The client may not recognize the early symptoms of PIH
Correct Answer: D
Rationale: Mild PIH is not treated with medications. Emotional stress is not the cause of blood pressure elevation in PIH. Excessive caloric intake is not the cause of weight gain in PIH. The client most frequently is not aware of the signs and symptoms in mild PIH.
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A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Correct Answer: C
Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
- A. Deep depression
- B. Psychotic depression
- C. Severe anxiety
- D. Severe depression
Correct Answer: D
Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
The nurse is preparing to administer insulin to a client with type 1 diabetes. The client is to receive 10 units of NPH insulin and 5 units of regular insulin in the same syringe. Which action is correct?
- A. Draw up the regular insulin first, then the NPH insulin.
- B. Draw up the NPH insulin first, then the regular insulin.
- C. Mix the insulins in a separate vial before drawing up.
- D. Administer the insulins in two separate injections.
Correct Answer: A
Rationale: To prevent contamination, draw up regular (clear) insulin first, then NPH (cloudy). Mixing in a vial (C) is incorrect, and separate injections (D) are unnecessary.
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
- A. Deviation of the trachea to the unaffected side
- B. Muffled heart sounds on the affected side
- C. Increased breath sounds on the affected side
- D. Decreased chest movement on the affected side
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.