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Questions 158

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Question 1 of 5

The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which recommendation is most appropriate?

Correct Answer: B

Rationale: Reducing sodium intake lowers blood pressure in hypertension by decreasing fluid retention. Exercise should be regular, caffeine avoided, and stress management encouraged.

Question 2 of 5

Which actions should be utilized prior to performing a tub bath on the 80 year-old client?

Question Image

Correct Answer: B, D

Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (
B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (
D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (
A) risks burns, and maintaining water flow pressure (
C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.

Question 3 of 5

Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:

Correct Answer: A

Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.

Question 4 of 5

What information should the nurse give a new mother regarding the introduction of solid foods for her infant?

Correct Answer: B

Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.

Question 5 of 5

Which of the following activities have been associated with an increase in lead exposure?

Question Image

Correct Answer: A, C, D, F

Rationale: Lead exposure risks include stained glass work (
A), restoring old toys (
C), decorative mugs (
D), and pre-1950 homes (F) due to lead-based paint or glazes. Disposable bottles (
B) and non-stick cookware (E) are not significant sources.

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