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When obtaining a health history from this client, which finding strongly suggests that the client is hypertensive? Select all that apply.
- A. Unexplained nosebleeds
- B. Difficulty sleeping at night
- C. Waking to urinate at night
- D. Occasional heart palpitations
- E. Dizziness
- F. Pale skin color
Correct Answer: A,C,E
Rationale: Unexplained nosebleeds, waking to urinate at night (nocturia), and dizziness are symptoms associated with hypertension due to increased vascular pressure, kidney effects, and cerebral hypoperfusion, respectively.
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The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?
- A. Sponge the client's forehead.
- B. Obtain a pulse oximetry reading.
- C. Take the client's vital signs.
- D. Assist the client to a sitting position.
Correct Answer: D
Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (D) improves breathing by reducing preload. Sponging (A), pulse oximetry (B), and vital signs (C) are secondary to positioning.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?
- A. Explain the importance of tapering off the medication.
- B. Discuss that the medication will make the client drowsy.
- C. Instruct the client to take the medication with food.
- D. Tell the client to take the medication when the pain level is around '8.'
Correct Answer: C
Rationale: NSAIDs irritate the stomach; taking with food (C) reduces GI upset. Tapering (A) is for steroids, drowsiness (B) is not typical, and waiting for severe pain (D) delays relief.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.
After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.