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Which signs/symptoms would the nurse expect to find in the female client diagnosed with Marfan’s syndrome?
- A. Xerostomia, dry eyes, and complaints of a dry vagina.
- B. A triad of arthritis, conjunctivitis, and urethritis.
- C. Very tall stature and long bones in the hands and feet.
- D. Spinal deformities of the vertebral column and malaise.
Correct Answer: C
Rationale: Marfan’s syndrome causes tall stature and long extremities (C) due to connective tissue defects. Dryness (A) is Sjögren’s, triad (B) is reactive arthritis, and spinal deformities (D) are partial but not primary.
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The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.
The nurse is monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.
The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach the clients?
- A. The blood pressure target range should be 120/80.
- B. Take the medication even when feeling well.
- C. Get up quickly when rising from a recumbent position.
- D. Consume a 3,000-mg sodium diet.
Correct Answer: B
Rationale: Hypertension requires lifelong medication, even when asymptomatic (B). Target BP (A) is <130/80, rapid rising (C) risks orthostasis, and 3,000 mg sodium (D) is too high (aim <2,000 mg).
Which nursing instruction is most beneficial in helping relieve the client's symptoms caused by varicose veins?
- A. Elevate your legs frequently during the day.
- B. Keep the room temperature above 70°F (21°C).
- C. Massage your calves when experiencing leg cramps.
- D. Modify your lifestyle to include sedentary activities.
Correct Answer: A
Rationale: Elevating the legs promotes venous return, reducing swelling and discomfort associated with varicose veins.
The client asks the nurse why they need to take a diuretic for hypertension. What is the best response?
- A. It helps your heart pump more efficiently.
- B. It reduces the amount of fluid in your blood vessels.
- C. It prevents blood clots from forming.
- D. It relaxes the blood vessel walls.
Correct Answer: B
Rationale: Diuretics reduce blood volume by increasing urine output, lowering pressure in blood vessels.