The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?

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Question 1 of 9

The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?

Correct Answer: B

Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.

Question 2 of 9

A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?

Correct Answer: D

Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.

Question 3 of 9

A nurse is conducting a nursing health history. Which component will the nurse address?

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. In a nursing health history, the nurse focuses on understanding the patient's expectations, needs, and preferences to provide patient-centered care. This step is essential for building rapport, establishing trust, and tailoring care plans to meet the patient's individual needs. Incorrect choices: A: Nurse’s concerns - This is not the primary focus during a nursing health history. The nurse should prioritize understanding the patient's perspective. C: Current treatment orders - While important, this is typically addressed during the assessment phase, not specifically in the nursing health history. D: Nurse’s goals for the patient - The nurse's goals should align with the patient's goals, making understanding the patient's expectations crucial.

Question 4 of 9

An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

Correct Answer: C

Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.

Question 5 of 9

A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?

Correct Answer: D

Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count. Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.

Question 6 of 9

A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?

Correct Answer: D

Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.

Question 7 of 9

If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?

Correct Answer: D

Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.

Question 8 of 9

An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?

Correct Answer: A

Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.

Question 9 of 9

A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Develop good communication skills. In interdisciplinary collaboration, effective communication is essential for teamwork. By developing good communication skills, the nurse can effectively interact with other healthcare professionals to provide holistic care. Choice A is incorrect as the nurse should collaborate as part of a team, not necessarily be the leader. Choice C is incorrect as interdisciplinary collaboration involves working with professionals from various disciplines. Choice D is incorrect as conflict resolution is an important aspect of effective collaboration.

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