melissa smith came to the emergency department in the last week before herestimated date of confinement complaining of headaches blurred vision and v
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Nursing Elites

NCLEX-PN

Quizlet NCLEX PN 2023

1. Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa's complaints with which of the following statements?

Correct answer: B

Rationale: Pregnancy-induced hypertension (PIH) is a hypertensive disorder of pregnancy that can present after 20 weeks gestation. It is characterized by symptoms like edema, hypertension, and proteinuria, which can progress to conditions like pre-eclampsia and eclampsia. The best approach for a client with advanced PIH is rest, and home provides the most suitable environment for it. Hospitalization is not typically necessary for PIH unless there are severe complications. Medication alone is not the primary intervention for PIH; management often involves monitoring, rest, and close medical supervision. Therefore, advising bedrest at home is the most appropriate response to help manage PIH symptoms and prevent further complications, such as pre-eclampsia or eclampsia. The other options, like hospitalization for observation, emphasizing the danger of the signs without providing guidance, or assuming medication as the primary solution, are not in line with the standard management approach for PIH.

2. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?

Correct answer: B

Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.

3. A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?

Correct answer: B

Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.

4. What is the most common cause of acute renal failure?

Correct answer: A

Rationale: The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.

5. After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?

Correct answer: A

Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.

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