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1. How should a healthcare professional assess a patient with chest pain?
- A. Assess the severity of pain and monitor ECG
- B. Administer nitroglycerin and provide oxygen
- C. Administer aspirin and provide pain relief
- D. Monitor for nausea and administer IV fluids
Correct answer: A
Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.
2. Which assessment finding is expected with myxedema?
- A. Increased pulse rate
- B. Decreased temperature
- C. Fine tremors
- D. Weight loss
Correct answer: B
Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.
3. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 150/80 mm Hg
- B. Swelling in the legs
- C. Persistent cough
- D. Heart rate of 72 beats per minute
Correct answer: C
Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.
4. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?
- A. High workload
- B. Limited knowledge on the subject
- C. Poor lighting
- D. Limited space in the learning area
Correct answer: C
Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.
5. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Pressured speech
- B. Increased appetite
- C. Lack of sleep
- D. Mood swings
Correct answer: C
Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.
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