Nokea
A client hospitalized with acute glomerulonephritis has a positive ASO titer. The nurse understands that the client's current illness is due to a:
- A. History of uncontrolled hypertension
- B. Prior bacterial infection
- C. Prolonged elevation in blood glucose
- D. Drug reaction that led to muscle breakdown
Correct Answer: B
Rationale: A positive antistreptolysin titer indicates infection with Group A β-hemolytic Streptococcus, a bacterial infection. Answers A, C, and D are not associated with acute glomerulonephritis so they are incorrect.
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The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus.
- A. What should the nurse expect the physician to order for a client with type I diabetes and morning SMBG readings of 205 mg/dL and 233 mg/dL?
- B. Reduce the client’s diet to 1,500 calorie ADA.
- C. Order 3 additional units of NPH insulin at 10 PM.
- D. Order an additional 10 units of regular insulin at 8 PM.
- E. Eliminate the client’s bedtime snack.
Correct Answer: B
Rationale: Elevated morning blood glucose levels suggest the dawn phenomenon, where blood sugar rises in the early morning due to hormonal changes. Adding 3 units of NPH insulin at 10 PM addresses this by providing longer-acting insulin coverage. Reducing the diet, adding regular insulin, or eliminating the snack does not target the dawn phenomenon effectively.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. The nurse performs range-of-motion (ROM) exercises for a client with second- and third-degree burns of the chest.
- B. The nurse sits with a client who suffers from depression while he eats his lunch.
- C. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
- D. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
Correct Answer: C
Rationale: Strategy: 'Negligence' indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct-delay in medication may cause difficulty in swallowing, might have difficulty taking medication (4) minor can request birth control without the parent's consent
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
- A. She is in an early stage of normal grief.
- B. She may be hallucinating.
- C. She may be having illusions.
- D. She may be in a severe depression.
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.