Nokea
Which one of the following situations represents a maturational crisis for the family?
- A. A four-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
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A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
- A. Weight gain
- B. Weight loss
- C. Tachycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.
The client is diagnosed with glaucoma. Which medication is most likely to be prescribed?
- A. Timolol (Timoptic)
- B. Atropine (Isopto Atropine)
- C. Pilocarpine (Isopto Carpine)
- D. Acetazolamide (Diamox)
Correct Answer: A
Rationale: Timolol, a beta-blocker, is commonly prescribed for glaucoma to reduce intraocular pressure by decreasing aqueous humor production. Atropine increases pressure, pilocarpine is less common, and acetazolamide is used acutely.
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
- A. A large gush of clear fluid from the vagina
- B. Systolic hypertension
- C. Abdominal rigidity
- D. Increased fetal movements
Correct Answer: C
Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
Priapism may be a sign of:
- A. Altered neurological function
- B. Imminent death
- C. Urinary incontinence
- D. Reproductive dysfunction
Correct Answer: A
Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.