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To prevent symptoms of Raynaud's, the client should:
- A. Avoid a high-sodium diet
- B. Take a brisk, 15-minute walk daily
- C. Avoid exposure to cold
- D. Increase her vitamin C intake
Correct Answer: C
Rationale: Avoiding cold exposure is key to preventing vasospasms in Raynaud's disease, which cause symptoms like numbness and color changes in the extremities.
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After receiving an annual influenza immunization, a client develops symptoms suggestive of Guillain-Barré syndrome. Which symptom is associated with Guillain-Barré syndrome?
- A. Paresthesia and weakness of the lower extremities
- B. Hyperactive deep tendon reflexes
- C. Emotional lability
- D. Flapping tremors of the hand and feet
Correct Answer: A
Rationale: Guillain-Barré syndrome causes paresthesia and weakness in the lower extremities , progressing upward. Reflexes are hypoactive (B is incorrect). Emotional lability and tremors are not typical.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
- A. The client states that he will not spend much time in the sun.
- B. The client says to the nurse, 'Is this the correct way to check my pulse? I want to do it right.'
- C. The client tells the nurse he will be very careful to sit on the edge of the bed for a few moments before standing up.
- D. The client says, 'I will not take Cialis while I am taking this medicine.'
Correct Answer: B
Rationale: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
The nurse should anticipate the client with a gastric ulcer to have pain
- A. two to three hours after a meal.
- B. at night.
- C. relieved by ingestion of food.
- D. one-half to one hour after a meal.
Correct Answer: D
Rationale: pain related to a gastric ulcer occurs about one-half to one hour after a meal and rarely at night; is not helped by ingestion of food
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously q12h. The nurse should monitor for which of the following as a side effect?
- A. Increased urine output.
- B. Bruising at the injection site.
- C. Elevated blood pressure.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Heparin can cause bruising at injection sites due to its anticoagulant effect. Options A, C, and D are not typical side effects.