Nokea
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. What is priority in teaching the child and family about this drug?
- A. The child should carry a nasal spray for emergency use
- B. The family must observe the child for dehydration
- C. Parents should administer the daily intramuscular injections
- D. The client needs to take daily injections in the short-term
Correct Answer: A
Rationale: Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.
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A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get the provider's discharge order.
- E. Cbe released because you are still suicidal.
- F. You can be released only if you sign a no suicide contract.
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
- A. Fat, tendons, and bones
- B. Skin and hair
- C. Nerves, muscle, and blood vessels
- D. Skin, fat, and muscle
Correct Answer: A
Rationale: Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury. Answer B has intermediate resistance, so it is incorrect. Answer C is incorrect because it has very low resistance. Answer D has low to intermediate resistance, so it is incorrect.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
- A. What should the nurse do if the patient’s left leg is externally rotated?
- B. Place a trochanter roll on the outer aspect of the thigh.
- C. Perform resistive range of motion of the left leg.
- D. Adduct and internally rotate the left leg.
- E. Instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?
- A. Anxiety related to the mastectomy.
- B. Impaired skin integrity related to the mastectomy.
- C. Pain related to surgical incision.
- D. Self-care deficit related to dressing changes.
Correct Answer: C
Rationale: immediately after surgery, the priority is optimizing the client's comfort