Nokea
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation of the aorta often results in weak or absent femoral pulses due to reduced blood flow to the lower extremities.
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Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
- A. Administer oral acetaminophen.
- B. Cover the adolescent with a thermal blanket
- C. Submerge the adolescent's feet in ice water
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. Hyperthermia can lead to seizures due to the brain's sensitivity to high temperatures. Seizure precautions involve ensuring a safe environment, padding the bed, and having emergency equipment ready. Administering oral acetaminophen (A) is not the priority in hyperthermia as it may not rapidly reduce the temperature. Covering with a thermal blanket (B) may further increase body temperature. Submerging feet in ice water (C) can cause vasoconstriction and shivering, leading to increased core temperature.
Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
Which of the following findings should the nurse expect?
- A. Spotting
- B. Nausea
- C. Polyhydramnios
- D. Uterine tenderness
Correct Answer: A
Rationale: The correct answer is A: Spotting. Spotting is a common finding in early pregnancy due to implantation bleeding or hormonal changes. It is often a normal occurrence, especially in the first trimester. Nausea (choice B) is another common finding in early pregnancy, known as morning sickness. Polyhydramnios (choice C) is an excessive accumulation of amniotic fluid and is not typically an expected finding. Uterine tenderness (choice D) can be a sign of infection or other issues, not a typical finding in early pregnancy.
The nurse should first address the client's.... followed by the client's....
- A. lung, sounds
- B. pain level
- C. bowel sounds
- D. blood glucose level
- E. blood pressure
- F. temperature
Correct Answer: E,F
Rationale: The correct answer is E,F. Firstly, addressing the client's blood pressure (E) is crucial as it assesses cardiovascular health and can indicate potential immediate risks. Secondly, addressing the client's temperature (F) is important as it can indicate infection or other health issues. Choices A, B, C, and D are not the priority as they do not directly relate to immediate cardiovascular or infection risks like blood pressure and temperature do.