Nokea
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never acted this way before. The nurse's best response is:
- A. I understand your concern. Let's discuss what specific changes you've noticed.'
- B. Delirium is common in older adults and usually resolves quickly.'
- C. We'll run some tests to find out what's causing this behavior.'
- D. Don't worry, we'll take good care of her.'
Correct Answer: A
Rationale: Discussing specific changes encourages the daughter to provide details, aiding in identifying the delirium's cause and tailoring care.
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A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence. He tells the nurse that he has decreased his fluid intake because of the incontinence. What would be the nurse's best response to the client?
- A. Yes, limiting your fluids can decrease your incontinence.'
- B. Limiting your fluids will cause kidney stones.'
- C. I think eight glasses of water a day and urinate every 2 hours.'
- D. If your incontinence continues, we will reinsert your catheter.'
Correct Answer: C
Rationale: Encouraging adequate fluid intake (eight glasses) and scheduled voiding (every 2 hours) helps manage incontinence and maintain urinary health post-TURP.
A 9-year-old child is newly diagnosed with type 1 diabetes mellitus. The nurse is planning for home care with the child and the family and determines that which is an age-appropriate activity for health maintenance?
- A. Administering insulin drawn up by an adult
- B. Self-administering insulin with adult supervision
- C. Making independent decisions with regard to sliding-scale coverage of insulin
- D. Having an adult assist in the self-administration of insulin and glucose monitoring
Correct Answer: B
Rationale: School-age children have the cognitive and motor skills to draw up and administer insulin with adult supervision. Developmentally, they do not yet have the maturity to make independent decisions such as about sliding-scale coverage without adult validation. Options requiring adult to manage insulin administration and glucose monitoring suppress the maximum level of independence appropriate to the level of this child.
The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a (n):
- A. Sentinel event.
- B. System variance.
- C. Adverse effect.
- D. Provider variance.
Correct Answer: B
Rationale: The lack of necessary supplies and equipment is a system variance , as it reflects a failure in the healthcare system's resources, impacting safe care delivery.
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client is a diabetic and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's:
- A. Diabetic neuropathy
- B. Muscle atrophy
- C. Raynaud's disease
- D. Transient ischemic attacks
Correct Answer: A
Rationale: Diabetic neuropathy likely causes the client's leg discomfort, making low-impact, intermittent stationary cycling suitable to avoid exacerbating symptoms. Other conditions are less likely causes.
Select the risk factor that is accurately paired with its disorder.
- A. Hypernatremia: Hepatic failure
- B. Hypocalcemia: Vitamin A deficiency
- C. Hypermagnesemia: Cushing's disease
- D. Hypomagnesemia: Crohn's disease
Correct Answer: D
Rationale: Hypomagnesemia is associated with Crohn's disease due to malabsorption and chronic diarrhea, which lead to magnesium loss.