Nokea
A 23-year-old woman who is 16 weeks pregnant is seen by the nurse for a routine maternal-child clinic appointment. The client has had erratically controlled type 1 diabetes since 12 years old. The client asks the nurse if she is at risk during her pregnancy. The nurse instructs the client she should do which of the following actions to limit complications for both her and her baby? Select all that apply.
- A. eat healthy foods
- B. refrain from exercise
- C. take medications as directed
- D. monitor her blood sugar before every meal
Correct Answer: A, C, D
Rationale: Healthy eating, taking insulin as directed, and monitoring blood sugar before meals help control diabetes and reduce pregnancy complications. Exercise is generally encouraged, not avoided.
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A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, 'I don't believe the doctor; I think he has me confused with another patient.' This is an example of which of Kubler-Ross' stages of dying?
- A. Denial
- B. Anger
- C. Depression
- D. Bargaining
Correct Answer: A
Rationale: The client's statement reflects denial, a stage where patients refuse to accept a terminal diagnosis, per Kubler-Ross' model.
What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
- A. Hypertension
- B. Lassitude
- C. Fatigue
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: Glomerulonephritis often causes hypertension due to fluid retention and renal dysfunction.
All of the following statements regarding scarlet fever are true EXCEPT
- A. rheumatic fever is a possible complication of scarlet fever.
- B. scarlet fever can be treated with antibiotics.
- C. a vaccine is available to protect against scarlet fever.
- D. scarlet fever is caused by an erythrogenic toxin.
Correct Answer: C
Rationale: No vaccine exists for scarlet fever, which is caused by Streptococcus pyogenes’ erythrogenic toxin and treated with antibiotics. Rheumatic fever is a complication.
Which of the following would be considered a sensible type of fluid loss?
- A. sweat
- B. respiratory excretions
- C. vomit
- D. water loss in feces
Correct Answer: A
Rationale: Sensible fluid loss is measurable, such as sweat or urine. Respiratory excretions, vomit, and fecal water loss are insensible (not easily measured).
The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
- A. 30 minutes before meals
- B. With each meal
- C. In a single dose at bedtime
- D. 60 minutes after meals
Correct Answer: C
Rationale: Ranitidine is most effective when taken at bedtime to suppress nocturnal acid production in erosive gastritis.