Nokea
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assess vital signs
- D. Assign her to a room with someone her own age
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
You may also like to solve these questions
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
- A. Bananas
- B. Broccoli
- C. Salmon
- D. Pasta
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
- A. A pull toy to encourage locomotion
- B. A mobile to improve hand-eye coordination
- C. A large toy with movable parts to improve pincer grasp
- D. Various large colored blocks to teach visual discrimination
Correct Answer: A
Rationale: Increased locomotive skills make push-pull toys appropriate for the energetic toddler. Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Correct Answer: C
Rationale: Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. The side effects of morphine sulfate include respiratory depression. Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
- A. D50W by IV push
- B. NPH insulin SC
- C. Regular insulin by IV infusion
- D. Sweetened grape juice by mouth
Correct Answer: C
Rationale: Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies.
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Constipation
- B. Urinary frequency
- C. Breast tenderness
- D. Abdominal pain
Correct Answer: D
Rationale: Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption, requiring immediate medical attention.