Nokea
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
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A client has a history of fibrocystic disorder of the breasts. The nurse determines that the client understands the nature of the disorder when the client states that symptoms are most likely to occur at which time?
- A. After menses
- B. Before menses
- C. In the spring months
- D. In the winter months
Correct Answer: B
Rationale: Fibrocystic breast disorder is characterized by cyclical breast pain and tenderness due to hormonal fluctuations, with symptoms most pronounced before menses when estrogen levels peak, leading to breast tissue swelling and cyst formation. Symptoms typically subside after menses. Seasonal changes, such as spring or winter months, do not influence fibrocystic breast symptoms.
A parent of a 9-year-old child newly diagnosed with diabetes mellitus is very concerned about the child going to school and participating in social events. The nurse creating a plan of care should formulate which goals to address these concerns? Select all that apply.
- A. The child's normal growth and development will be maintained.
- B. The child will use effective coping mechanisms to manage anxiety.
- C. The child and family will discuss all aspects of the illness and its treatments.
- D. The child and family will integrate diabetes care into patterns of daily living.
- E. The child and family will discuss their concerns with the child's teachers and the school nurse.
Correct Answer: D,E
Rationale: To effectively manage social events in the child's life, the family and the child need to integrate the care and management of diabetes into their daily living. In addition, the child's teachers and the school nurse should be aware of their concerns. The other options may be appropriate goals, but they do not deal with social issues.
Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
A client with a history of chronic pain is prescribed gabapentin (Neurontin). The nurse should instruct the client to report which of the following side effects?
- A. Drowsiness.
- B. Hypertension.
- C. Hyperglycemia.
- D. Tachycardia.
Correct Answer: A
Rationale: Gabapentin commonly causes drowsiness, which should be reported to manage safety and dosing.