Nokea
A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?
- A. Appetite
- B. Mood
- C. Withdrawal
- D. Energy level
Correct Answer: B
Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.
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A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?
- A. Hemoglobin 9.5 g/dL
- B. Potassium 6.2 mEq/L
- C. Creatinine 3.5 mg/dL
- D. BUN 50 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.
While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?
- A. Endotracheal cuff pressure greater than 25 cm H2O.
- B. Decreased lung compliance during ventilation.
- C. Bilateral crackles with increased secretions.
- D. Restless client who is biting the endotracheal tube.
Correct Answer: D
Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.
A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?
- A. Compartment syndrome
- B. Deep vein thrombosis
- C. Wound infection
- D. All of the above
Correct Answer: A
Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.
The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. ''I will inspect my feet daily for any cuts or blisters.''
- B. ''I will soak my feet in warm water every day.''
- C. ''I will wear shoes that fit properly to avoid injury.''
- D. ''I will avoid walking barefoot to protect my feet.''
Correct Answer: B
Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.
The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?
- A. Monitor blood glucose levels regularly
- B. Maintain a low-fat diet
- C. Exercise regularly
- D. Take medication as prescribed
Correct Answer: A
Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.