Nokea
You have been conducting a weekly outpatient stress management educational series for clients in the community who are hypertensive. The best way to evaluate the effectiveness of this educational series is to:
- A. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.
- B. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data after the series is completed.
- C. Ask the clients how often they use the stress management techniques that they have learned during this educational series.
- D. Use a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series.
Correct Answer: A
Rationale: Collecting and comparing blood pressure data before, during, and after the series provides objective evidence of the program's effectiveness in managing hypertension.
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You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.
Which neurological complication can occur when a vest restraint is too tight around the client's body?
- A. Strangulation
- B. Skin breakdown
- C. Skin pallor
- D. Numbness
Correct Answer: A
Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.
Which of the following goals is most important for a client with acute pancreatitis?
- A. The client reports minimal pain.
- B. The client regains a normal pattern for bowel movements.
- C. The client limits alcohol intake to two to three drinks per week.
- D. The client maintains normal liver function.
Correct Answer: A
Rationale: Minimizing pain is the most important goal in acute pancreatitis to improve client comfort and recovery.
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Mirtazapine commonly causes weight gain.