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A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:
- A. I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.
- B. It is not too much trouble. This is the best way to manage urination.
- C. OK. I'll ask your physician if we can replace the Foley.
- D. You need to learn this because your doctor ordered it.
Correct Answer: A
Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.
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The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
- A. Hematuria
- B. Hypotension
- C. Weight loss
- D. Clear urine
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.
A client with Parkinson's disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect?
- A. The client no longer has intractable tremors.
- B. The client has sufficient production of dopamine.
- C. The client no longer requires any medication.
- D. The client will have increased production of serotonin.
Correct Answer: A
Rationale: Stereotactic surgery, such as deep brain stimulation, aims to reduce symptoms like intractable tremors in Parkinson's disease. It does not directly increase dopamine or serotonin production, nor does it eliminate the need for medication entirely.
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.
The nurse is preparing to administer a dose of ondansetron (Zofran) for nausea. Which route is most appropriate for rapid onset?
- A. Oral
- B. Intramuscular
- C. Intravenous
- D. Sublingual
Correct Answer: C
Rationale: Intravenous ondansetron provides the fastest onset for nausea relief, ideal in acute settings. Oral and sublingual routes are slower, and IM is less common.