Possible side effect related to liver damage - ANS-The nurse is caring for a client with
tuberculosis who is receiving isoniazid and rifampin for tuberculosis. Which adverse
effect should the nurse be most concerned with?
Dry cough - Vague sign
Acute confusion - Correct - sign of infection in an older adult
Increased temperature - Older adult may not exhibit normal signs of infection
Purulent drainage from incision - Older adult may not exhibit normal signs of infection -
ANS-What would the nurse expect to find in the care of an 80-year-old client who is
experiencing a complication after a right knee replacement? The patient is post-op day
1.
1
Dry cough
2
Acute confusion
3
Increased temperature
4
Purulent drainage from incision
48-year-old African-American male who is obese and father and mother have type 2
DM. - ANS-Which of these clients should the nurse consider at greatest risk for
developing type 2 diabetes mellitus?
,1
48-year-old African-American male who is obese and father and mother have type 2
DM.
2
50-year-old male hemoglobin A1C of 5.5% during a routine physical examination.
3
A 30-year-old female who delivered a 9-pound baby.
4
A 62-year-old male with an elevated triglyceride level.
"You should add a thickener all liquids and make sure he sits upright while eating." -
ANS-The nurse is assessing a client with Parkinson's disease who has been admitted to
the hospital because of significant weight loss. Assessment data reveals a masklike
facial expression and slurred speech. A swallowing evaluation reveals some difficulty
swallowing. The client's daughter asks the nurse, "How am I supposed to feed him at
home?" What is an appropriate response by the nurse?
1
"He will be scheduled for surgery to have a feeding tube placed".
2
"It's best to feed him only three meals a day to reduce the chance of choking."
3
"Make sure he drinks all liquids through a straw and recline in chair while eating."
4
"You should add a thickener all liquids and make sure he sits upright while eating."
"It appears you are hearing voices again. Tell me what you are hearing." - ANS-The
nurse is caring for a client who has been admitted to the psychiatric in-client unit with
schizophrenia. While talking with the nurse alone, the client suddenly stops
midsentence, turns to stare at the wall and states, "I told you I can't do that!" What is an
appropriate response by the nurse?
1
"I will talk to you later when you can pay attention."
2
"I will leave the room if you continue to not pay attention"
3
"Is your mother talking to you again? I wish she would leave you alone."
4
, "It appears you are hearing voices again. Tell me what you are hearing."
"I know that my blood pressure is high when my nose starts bleeding."
Correct - Hypertension is usually asymptomatic. A nose bleed can occur with high blood
pressure, but it can occur for many other reasons as well. It is quite common that the
client's blood pressure is high and the client experiences no symptoms. It is important to
help clients understand that they cannot rely on one particular symptom to tell if their
pressure is elevated. It would be very dangerous for clients to think their blood pressure
is only high if they have a nose bleed. - ANS-The nurse is participating in the discharge
plans for a client with hypertension. Which statement by the client would cause
concern?
1
"I am at risk for stroke or heart attack if my blood pressure is not controlled."
2
"I know that my blood pressure is high when my nose starts bleeding."
3
"I will take my blood pressure two times a day for at least 7 days."
4
"I will ask my spouse to start walking with me in the mornings."
pH 7.50.
CO2 28.
pH 7.50. Correct - pH level is elevated with respiratory alkalosis
pH 7.30. A low pH can indicate respiratory acidosis
carbon dioxide (CO2 ) 50. A high CO2 can indicate respiratory acidosis
CO2 28. Correct - In respiratory alkalosis, the client is blowing off too much CO2 which
leads to a low level.
Oxygen saturation 85%. Oxygen levels are usually normal in respiratory alkalosis.
Bicarbonate 25. Bicarbonate levels are usually normal in respiratory alkalosis -
ANS-The nurse is reviewing the client's lab values who has respiratory alkalosis. Which
results should the nurse expect? Select all that apply
1
pH 7.50.
2
pH 7.30.
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