Nokea
Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.
- A. Client with asthma exacerbation and blood pressure is 150/90 mm Hg
- B. Client with spinal cord injury and blood pressure is 50/60 mm Hg
- C. Client with coronary artery disease on metoprolol, pulse is 62/min
- D. Elderly client with black stool; pulse is 112/min
- E. Neonate crying inconsolably at feeding time; pulse is 160/min
Correct Answer: B,D,E
Rationale: Concerning conditions include: spinal cord injury with hypotension suggesting neurogenic shock; black stool and tachycardia indicating possible GI bleeding; and inconsolable neonate with tachycardia suggesting distress. Asthma with hypertension and stable pulse on metoprolol are less urgent.
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A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
The nurse is collecting data on a client with hypertension and essential tremor who received the first dose of propranolol 2 hours ago. Which assessment is most concerning to the nurse?
- A. Client reports a headache
- B. Current blood pressure is 160/88 mm Hg
- C. Heart rate has decreased from 70/min to 60/min
- D. Slight wheezes auscultated during inspiration
Correct Answer: D
Rationale: Wheezing post-propranolol is concerning for bronchospasm, a serious side effect in a patient with no known respiratory history. Headache , elevated BP , and mild heart rate decrease are less urgent.
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.
A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?
- A. I will launder recently worn clothing, sheets, and towels in hot water.'
- B. I will make sure all eating utensils are placed in the dishwasher.'
- C. I will spray the house with insecticide to control this problem.'
- D. I will throw away stuffed animals and toys that cannot be washed.'
Correct Answer: A
Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.
The nurse in the outpatient care facility is caring for a client who is blind. Which of the following actions should the nurse take?
- A. Offer the client's service dog food and water.
- B. Teach the client how to ambulate with a stability cane.
- C. Touch the client's shoulder before speaking to the client.
- D. Walk slightly ahead of the client with the client holding the nurse's elbow
Correct Answer: D
Rationale: Walking slightly ahead with the client holding the nurse's elbow is the standard technique for guiding a blind person safely. Offering food to a service dog is inappropriate, teaching cane use assumes need, and touching without warning may startle.