A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?

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Question 1 of 5

A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?

Correct Answer: A

Rationale: The correct answer is A: Inform the physician. This is essential because a sudden change in vital signs may indicate a critical condition that requires immediate medical attention. The physician needs to be informed promptly to assess the situation and provide appropriate interventions. Summary: - B: Changing environmental settings is not a priority when dealing with sudden changes in vital signs. - C: Altering diet intake is not an immediate response to sudden changes in vital signs. - D: Decreasing physical activity may not address the underlying cause of the sudden change in vital signs.

Question 2 of 5

A 48-year-old patient has been prescribed trihexyphenidyl for her Parkinson’s disease. Which adverse reaction to this drug can be close-related?

Correct Answer: C

Rationale: Correct Answer: C - Dryness of mouth Rationale: 1. Trihexyphenidyl is an anticholinergic medication commonly used to treat Parkinson's disease. 2. Anticholinergic drugs inhibit the parasympathetic nervous system, leading to decreased secretions. 3. Dryness of mouth (xerostomia) is a common side effect of anticholinergic medications. 4. Excessive salivation, bradycardia, and constipation are not typically associated with anticholinergic drugs, making them incorrect choices.

Question 3 of 5

The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:

Correct Answer: A

Rationale: Rationale: A relaxed face during conversation typically does not indicate a hearing loss, as the patient is likely able to hear and understand. B, speaking loudly, is a common sign of hearing loss. C, turning towards the speaker, suggests an effort to hear better. D, being withdrawn, could indicate difficulty in communication due to hearing loss. Therefore, A is the correct answer as it does not align with typical signs of hearing loss.

Question 4 of 5

Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?

Correct Answer: A

Rationale: The correct answer is A: Hearing loss, vertigo, and tinnitus. Meniere's disease is characterized by a triad of symptoms: recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus. Vertigo is a spinning sensation, hearing loss affects the inner ear, and tinnitus is ringing in the ear. Nausea, vomiting, pain, nystagmus, or headache are not typically part of the classic triad of Meniere's disease symptoms. Therefore, option A is the most appropriate choice based on the specific symptomatology associated with Meniere's disease.

Question 5 of 5

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

Correct Answer: A

Rationale: The correct answer is A because it demonstrates an understanding of the key factors in managing hyperosmolar hyperglycemic nonketotic syndrome (HHNS), which include avoiding dehydration and being aware of changes in urination, thirst, and hunger. This statement shows awareness of the importance of maintaining hydration and recognizing early signs of worsening symptoms. Choice B is incorrect as consuming sugary soda can exacerbate the condition by further increasing blood sugar levels. Choice C is incorrect because while monitoring blood glucose levels is important, it is not the primary method of preventing HHNS. Choice D is incorrect because consuming high-carbohydrate snacks can contribute to elevated blood glucose levels, which is counterproductive in managing HHNS.

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