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 promotes self-awareness and accountability, which are essential in chronic illness management.

🟢 Documenting symptoms provides important data for evaluating treatment effectiveness and guiding adjustments.

🟢 It empowers the client to recognize triggers and patterns in their anginal episodes, leading to better prevention.

🟢 Encouraging proactive tracking rather than passive education supports long-term adherence to the treatment plan.

🟢 It is measurable and focuses on real-time symptom surveillance, critical for ischemic heart disease.

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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 :

🟡 A. Measure BP in both arms — Helps assess for hypertension or vascular abnormalities, especially with central obesity.

🟡 B. Screen for diabetes history — Abdominal obesity is strongly linked to insulin resistance and metabolic syndrome.

🟡 E. Promote regular exercise — Physical activity is a cornerstone in managing BMI, blood pressure, and glucose regulation.

🟡 Fluid restriction (D) and emergency transport (C) are not indicated in the absence of acute symptoms.

🟡 This question reflects a preventive health approach targeting modifiable risk factors.

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Answer 3

Correct Answers:

Attempt to ask the client simple questions.

Rationale :

🟣 Suspicious, guarded behavior may reflect paranoia or psychotic symptoms.

🟣 Approaching the client with simple, non-threatening questions demonstrates respect for boundaries and promotes rapport building.

🟣 Postponing or delegating the task can delay care and worsen mistrust.

🟣 This approach helps initiate therapeutic communication, essential for assessment and intervention.

🟣 Establishing a sense of safety may eventually lead to full engagement.

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Answer 4

Correct Answers:

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

Rationale :

🟢 Lithium has a narrow therapeutic index, and factors like hydration, diet, and medication adherence can influence serum levels.

🟢 College life introduces routine changes that may affect lithium metabolism, increasing the risk for toxicity or subtherapeutic dosing.

🟢 Regular monitoring ensures safe continuation of therapy and allows for early detection of side effects.

🟢 While awareness and therapy are valuable, laboratory monitoring is most critical to safety.

🟢 Family education should emphasize the importance of serum testing during transitional life stages.

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Answer 5

Correct Answers:

Evidence of patches of lost hair.

Rationale :

🟡 The presence of multiple small bald patches that are hidden suggests trichotillomania, a psychiatric condition involving repetitive hair pulling.

🟡 This behavior is often associated with stress, anxiety, or trauma, especially in children.

🟡 Unlike scalp infections or dermatologic causes, this type of hair loss is often non-inflammatory and patterned.

🟡 The child's attempt to conceal the bald spots reflects embarrassment or avoidance, a common emotional response to self-inflicted behaviors.

🟡 Prompt recognition leads to referral for mental health evaluation and behavioral therapy

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Answer 6

Correct Answers:

Evidence of patches of lost hair.

Rationale :

🟡 The presence of multiple small bald patches that are hidden suggests trichotillomania, a psychiatric condition involving repetitive hair pulling.

🟡 This behavior is often associated with stress, anxiety, or trauma, especially in children.

🟡 Unlike scalp infections or dermatologic causes, this type of hair loss is often non-inflammatory and patterned.

🟡 The child's attempt to conceal the bald spots reflects embarrassment or avoidance, a common emotional response to self-inflicted behaviors.

🟡 Prompt recognition leads to referral for mental health evaluation and behavioral therapy

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Answer 7

Correct Answers:

Focus on small achievable tasks, not taxing problems.

Rationale :

🔵 Depression causes cognitive slowing and reduced motivation, making large tasks overwhelming.

🔵 Small, manageable goals foster confidence, productivity, and therapeutic engagement.

🔵 This strategy promotes behavioral activation, a core principle in managing depressive symptoms.

🔵 Accomplishing simple tasks helps clients regain a sense of control and purpose.

🔵 It supports the client’s transition from avoidance behaviors (e.g., TV watching) to meaningful action.

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Answer 8

Correct Answers:

Medication history.

Rationale :

🟣 Prior to starting sertraline (an SSRI), it's essential to assess for use of MAOIs, triptans, or other serotonergic agents to prevent serotonin syndrome.

🟣 The medication history also identifies previous antidepressant responses, potential allergies, and drug-drug interactions.

🟣 Safety hinges on avoiding combinations that could cause hypertensive crisis or CNS toxicity.

🟣 While weight and family history provide valuable context, medication reconciliation is the priority.

🟣 This supports safe initiation and maintenance of pharmacologic therapy.

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Answer 9

Correct Answers:

Stimulation and dilated pupils.

Rationale :

🔴 Cocaine is a potent stimulant, and recent use results in increased sympathetic activity, including hyperalertness, agitation, mydriasis (dilated pupils), tachycardia, and possible paranoia.

🔴 Unlike depressants, it does not cause sedation or bradycardia.

🔴 The nurse should monitor for signs of cardiovascular strain or psychotic features, especially with repeated use.

🔴 These observations guide the nurse in determining risk and urgency of intervention.

🔴 Pupil size is a key physical indicator during substance use assessments.

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Answer 10

Correct Answers:

hyperkalemia

Rationale :

🟢 The client missed dialysis for 3 days and presents with muscle cramps, paresthesia, weakness, tachycardia, and peaked T-waves, all classic signs of hyperkalemia.

🟢 In end-stage renal disease (ESRD), potassium is not adequately excreted, leading to life-threatening cardiac arrhythmias if untreated.

🟢 The nurse must prioritize potassium monitoring, cardiac rhythm assessment, and emergency dialysis or medication protocols (e.g., insulin + glucose + calcium gluconate).

🟢 This condition is a critical emergency, especially when ECG changes are present.

🟢 Recognizing this electrolyte imbalance early can prevent sudden cardiac arrest.

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QLexNursing

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 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?

7 :
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?

8 :
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

9 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

10 :
The client is a 68-year-old presents to the emergency department (ED) .

Answer Options

QLexNursing

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 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?

7 : 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?

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

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

10 : The client is a 68-year-old presents to the emergency department (ED) .

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 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?

7 :
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?

8 :
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

9 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

10 :
The client is a 68-year-old presents to the emergency department (ED) .