Question

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

Answer 1

Correct Answers:

The client will record episodes of angina and self-management for one week.

Rationale :

📝This outcome focuses on client self-monitoring, which is essential in managing chronic conditions like hypertension and angina.

📋By tracking episodes of chest pain and the associated self-management interventions, the nurse can evaluate the effectiveness of current treatment strategies.

🩺Encouraging documentation increases client engagement and provides crucial data for modifying the care plan.

📚This goal is measurable and client-centered, unlike options that focus only on the nurse’s actions.

📌Core Message

Client self-monitoring, documentation of symptoms, and engagement in care are essential for managing chronic conditions like angina.

Answer 2

Correct Answers:

Measure the client's blood pressure in both arms.
Screen for a family history of diabetes mellitus.
Discuss the importance of a regular exercise program.

Rationale :

🩺Abdominal obesity and high BMI are indicators of metabolic syndrome, increasing the risk for hypertension and diabetes.

🧬Family history of diabetes is a known risk factor and should be screened to guide preventive strategies.

🏃Regular exercise plays a key role in reducing cardiometabolic risk and improving overall health.

🩹Measuring BP in both arms helps detect vascular abnormalities and cardiovascular disease.

📌Core Message

Assessing cardiovascular risk, evaluating family history, and promoting exercise help address obesity-related complications.

Answer 3

Correct Answers:

Attempt to ask the client simple questions.

Rationale :

🗣️Clients who are guarded or suspicious require a non-threatening approach to build trust.

💬Simple questions allow for gradual engagement without overwhelming the client.

🧠This technique respects the client’s mental state while still gathering essential information.

🤝Establishing rapport and safety is crucial in psychiatric assessments.

📌Core Message

Use simple questions to establish rapport with guarded psychiatric clients for effective communication.

Answer 4

Correct Answers:

The client's serum lithium levels should be routinely evaluated.

Rationale :

🧪Lithium has a narrow therapeutic index, and blood levels must be monitored regularly to prevent toxicity.

📉Missed doses, dehydration, or changes in routine can easily lead to lithium imbalance, especially in unsupervised environments.

🧠Monitoring levels is especially important during life transitions, such as moving away from home.

📅Educating both client and family ensures continuity of care and prevents relapse or complications.

📌Core Message

Routine monitoring of serum lithium levels is critical to ensure safe and effective therapy in bipolar clients.

Answer 5

Correct Answers:

Ecchymotic blood accumulations.

Rationale :

🩸Ecchymosis suggests mechanical trauma, not disease-related causes like alopecia areata or fungal infections.

👧Covering bald spots and reports of pain raise concern for possible abuse or hair-pulling injuries.

👀Patches of hair loss with bruising point to external causes, especially if inconsistent with natural skin conditions.

🛑The nurse must differentiate trauma vs. illness for proper intervention and reporting.

📌Core Message

Hair loss with bruising points toward non-disease causes and may require evaluation for abuse.

Answer 6

Correct Answers:

Focus on small achievable tasks, not taxing problems.

Rationale :

📉Clients with depression often experience low motivation and cognitive overload.

👀Focusing on small tasks fosters a sense of accomplishment and reduces feelings of helplessness.

🧘This technique helps promote self-efficacy and gradually improves functional capacity.

🧩It also helps clients regain structure and control, which are often lost in depressive states.

📌Core Message

Breaking down goals into small tasks aids in improving function and coping in clients with depression.

Answer 7

Correct Answers:

Medication history.

Rationale :

💊Knowing the medication history is vital to assess for potential drug interactions with sertraline.

🧠Sertraline is a selective serotonin reuptake inhibitor (SSRI), and combining it with other serotonergic agents may cause serotonin syndrome.

📋This assessment ensures safe initiation of therapy, especially in clients with complex regimens.

🩺It also aids in identifying contraindications, such as recent use of MAOIs.

📌Core Message

A thorough medication history is essential to prevent serotonin toxicity and ensure safe SSRI use.

Answer 8

Correct Answers:

Stimulation and dilated pupils.

Rationale :

⚡Cocaine is a central nervous system stimulant that leads to increased sympathetic activity.

👁️Dilated pupils (mydriasis), tachycardia, and agitation are common physiological effects.

🌀These signs reflect heightened arousal, unlike depressants which cause lethargy.

🔍Recognizing this helps guide accurate assessment and safety precautions during care.

📌Core Message

Cocaine use results in stimulation and pupil dilation, reflecting sympathetic overdrive.

Answer 9

Correct Answers:

hyperkalemia

Rationale :

⚠️Missing dialysis can lead to potassium buildup, as the kidneys are unable to excrete excess electrolytes.

💓Symptoms like muscle cramps, tingling, weakness, and lightheadedness are early signs of hyperkalemia.

🧪This condition is common in end-stage renal disease (ESRD), especially after skipping dialysis sessions.

🧯Untreated hyperkalemia can rapidly escalate to cardiac dysrhythmias or arrest, requiring urgent treatment.

📌Core Message

Hyperkalemia is a life-threatening complication in ESRD clients who miss dialysis sessions.

Answer 10

Correct Answers:

Basic metabolic panel
Chest X-ray
Place on a continuous cardiac monitor

Rationale :

🧪A basic metabolic panel is essential to evaluate electrolyte imbalances (especially potassium) due to missed dialysis.

📸A chest X-ray is necessary to rule out pulmonary edema or fluid overload, which are common in patients with ESRD and chest discomfort.

❤️Placing the client on a continuous cardiac monitor is vital to detect cardiac dysrhythmias, particularly given the presence of tachycardia and chest discomfort.

🔎These interventions are immediately actionable and address potentially life-threatening complications of missed dialysis and fluid-electrolyte imbalance.

📌Core Message

Prioritize cardiac monitoring, electrolyte assessment, and chest imaging to detect and manage life-threatening complications in clients with ESRD.

1 :
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

2 :
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

3 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

5 :
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

6 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

7 :
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

8 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

9 :
The nurse is reviewing the client's data.

Answer Options

10 :
The nurse is reviewing the physician's orders.

Answer Options

1 : The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

2 : During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

3 : A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

5 : A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

6 : A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

7 : Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

8 : The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

9 : The nurse is reviewing the client's data.

Answer Options

10 : The nurse is reviewing the physician's orders.

Answer Options

1 :
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

2 :
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

3 :
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

5 :
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

6 :
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

7 :
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

8 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

9 :
The nurse is reviewing the client's data.

10 :
The nurse is reviewing the physician's orders.