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Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
- A. Slight increase in pulse
- B. Dry, warm skin
- C. Increased urine output
- D. Normal respirations
Correct Answer: A
Rationale: A. A slight increase in pulse is a common finding in hypovolemic shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain adequate perfusion.
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The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client?
- A. Infection
- B. Fluid volume
- C. Peripheral perfusion
- D. Sleep pattern
Correct Answer: C
Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data?
- A. Normal
- B. Hypertension stage I
- C. Prehypertension
- D. Hypertension stage II
Correct Answer: D
Rationale: A blood pressure reading of 142/92 mmHg falls into the category of Hypertension Stage II based on the guidelines from the American Heart Association. In this classification, systolic blood pressure is 140-159 mmHg and diastolic blood pressure is 90-99 mmHg. Stage II hypertension indicates that the individual has a significantly elevated blood pressure level that requires prompt management and monitoring. It is crucial for the nurse to document this accurately to ensure appropriate interventions are provided to the client.
A patient has heard of several friends being diagnosed with colon cancer and does not want to develop the same health problem. What should the nurse recommend to this patient? Select all that apply.
- A. Obtain regular exercise
- B. Maintain a healthy weight
- C. Ingest two servings of red wine every day
- D. Obtain recommended screening after age 50 e. Consume a diet high in fruit and vegetables and low in saturated fat and red meat
Correct Answer: A
Rationale: A. Regular exercise has been shown to reduce the risk of developing colon cancer. Exercise helps in maintaining a healthy weight, supporting the immune system, and promoting overall health.
The nurse is caring for an adult client who has been diagnosed with high cholesterol. Which is important for the nurse to consider when teaching this adult client?
- A. Adults are more oriented to learning when the material is useful immediately.
- B. Adults are more likely to adhere to a regimen than are children.
- C. Adults usually can find information on their own.
- D. Adults do not need to be evaluated for understanding as children do.
Correct Answer: A
Rationale: When teaching an adult client with high cholesterol, it is important for the nurse to consider that adults are more oriented to learning when the material is useful immediately. This means that providing practical information and emphasizing how managing high cholesterol can benefit their health in the short term is likely to be more effective in engaging the client and encouraging adherence to recommendations. By focusing on the immediate relevance and benefits of the information, the nurse can enhance the client's motivation and understanding of the importance of managing their high cholesterol levels.
During the physical examination of a client who took a fall that fractured his hip, the nurse notices an impairment of the client's hearing, but that the client's visual acuity and motor function do not seem to be impaired. The client answers questions very precisely and readily grasps the meaning of everything the nurse says when the client can face the nurse. When teaching this client, the nurse should make it a priority to
- A. make verbal instructions face to face with the client.
- B. provide only written instructions.
- C. use only visual media.
- D. use only physical demonstrations with written instructions.
Correct Answer: A
Rationale: The client in this scenario has an impairment of hearing, so it is essential to ensure effective communication by facing the client when providing verbal instructions. By facing the client, the nurse can help the client by making it easier to lip-read and pick up verbal cues, improving the client's ability to understand the instructions clearly. This approach demonstrates sensitivity to the client's needs and promotes better communication during teaching sessions. Providing written instructions alone (option B), using only visual media (option C), or relying solely on physical demonstrations with written instructions (option D) may not be as effective for this particular client with impaired hearing.