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The nurse recognizes that an early finding that indicates that a client is hypertensive is:

A diastolic blood pressure that remains greater than 90 mm Hg A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and indicates hypertension. An extended Korotkoff sound is unrelated to hypertension. An irregular pulse of 92 beats per minute reflects the heart rate and rhythm, not the pressure within the arteries. Initially hypertension usually is asymptomatic; although headaches can be associated with hypertension, there are other causes of headaches.

A nurse teaches a client who has had a thyroidectomy for thyroid cancer to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? (Select all that apply.)

Dry skin lethargy sensitivity to cold

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? ( Select all that apply.)

Fatigue Altered taste sensation Fatigue and altered taste sensations are major systemic problems caused by radiation therapy. Fatigue may be caused by the increased energy demands needed to repair damaged cells; taste changes are thought to be caused by metabolites released from dead and dying cells. Alopecia can occur when the hair on the head is in the field of radiation, but it is not a major side effect. Vomiting is not common unless the stomach or intestine receives radiation. Leukopenia is not a problem unless 25% or more of the bone marrow is in the treatment field.

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? (Select all that apply.)

Ice Tea Hot Cocoa Chocolate pudding Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition.

Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? (Select all that apply.)

Instruct the client to avoid crossing the legs Instruct the client to dorsiflex the feet routinely Avoiding crossing the ankles and legs relieves pressure against the veins in the legs and facilitates venous return. Alternating planter flexion and dorsiflexion contracts calf muscles, facilitating venous return. Drinking fluids keeps the client hydrated, preventing dehydration and hypercoagulability; however, this is not an independent function of the nurse because it requires a practitioner's prescription. Massaging the client's legs is contraindicated because any developing clot could be dislodged. Placing the client's legs in pneumatic stockings is not an independent function of the nurse. The nurse needs a health care practitioner's prescription to apply pneumatic stockings

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Oliguria irritability hypotension Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Decreased blood flow to the kidneys leads to oliguria or anuria. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client?

Provide frequent saline mouthwashes. Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral mucosa.

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:

Proximate cause Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury . Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract or trust that results in injury to another person. Common cause means to unite one's interest with another's.

A 75-year-old client has a baseline blood pressure of 140/90 mm Hg. The nurse obtains a sitting blood pressure in the client's left arm, and the reading is 160/100 mm Hg. What action should the nurse take next?

Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing. Further assessment is necessary before the nurse can plan a course of action. Advising the client to restrict fluid and sodium intake is not an initial nursing action; further assessment is the priority. The nurse must gather more data before consulting with the health care practitioner. This is not an expected blood pressure for an older adult; both systolic and diastolic pressures are elevated.

When obtaining the history of a client recently diagnosed with type 1 diabetes, the nurse expects to identify the presence of:

weightloss Protein and lipid catabolism occur because carbohydrates cannot be used by the cells; this results in weight loss and muscle wasting. Dehydration, not edema, is more likely to occur because of the polyuria associated with hyperglycemia. Polyphagia, not anorexia, occurs with diabetes as the client attempts to meet metabolic needs. Hyperglycemia, not hypoglycemia, is present in both type 1 and type 2 diabetes.