A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 9:00 AM
- B. 1:00 PM
- C. 11:00 AM
- D. 3:00 PM
Correct Answer: C
Rationale: This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. This time is incorrect because it is after lunch when the NPH peaks. Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. This time is incorrect because it is before the NPH and after the regular insulin peak times.
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The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
- A. Scarf sign
- B. Harlequin sign
- C. Cullen's sign
- D. Trendelenburg sign
Correct Answer: D
Rationale: Trendelenburg sign, where the pelvis tilts downward on the unaffected side when standing on the affected leg, is associated with congenital hip dysplasia due to weak hip abductors. The other signs are unrelated.
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Chloasma
- C. Dysuria
- D. Colostrum
Correct Answer: C
Rationale: Dysuria is abnormal and may indicate a urinary tract infection, unlike the other options, which are normal pregnancy changes.
The nurse is performing discharge teaching to the parents of a seven-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
- A. Baseball
- B. Swimming
- C. Football
- D. Track
Correct Answer: B
Rationale: Swimming is ideal for asthma patients, as the warm, humid air reduces bronchospasm risk. Baseball (A), football (C), and track (D) involve outdoor or high-exertion activities that may trigger asthma.
A client with a history of a thyroidectomy is receiving Calcitonin (Miacalcin). The nurse should monitor the client for:
- A. Hypocalcemia
- B. Hyperglycemia
- C. Hypotension
- D. Weight gain
Correct Answer: A
Rationale: Calcitonin lowers serum calcium, risking hypocalcemia, requiring monitoring for symptoms like tingling. Hyperglycemia, hypotension, and weight gain are not primary concerns.
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