Nokea
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
- A. Increased urine catecholamines
- B. Decreased TSH
- C. Erratic changes in BUN levels
- D. Increased blood glucose levels
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.
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An adult who has a hiatal hernia is seen in clinic. The nurse is reviewing her care with her. Which comment by the client indicates a need for more teaching about managing her condition?
- A. I sit up for an hour after eating.
- B. I miss drinking soda, but I know it is not good for me.
- C. I like to go swimming every day.
- D. I drink hot chocolate instead of coffee.
Correct Answer: D
Rationale: Hot chocolate contains caffeine, which can relax the lower esophageal sphincter, worsening hiatal hernia symptoms. Sitting up, avoiding soda, and swimming are appropriate for management.
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
- A. Playing with toys in a back yard flower garden
- B. Eating small amounts of grass while playing 'farm'
- C. Playing with cars on the pavement near burning leaves
- D. Throwing a ball to a neighborhood child who has poison ivy
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.
The nurse knows that
- A. these Test s are valuable screening Test s for prostatic cancer.
- B. the level of PSA is decreased in clients with renal stones.
- C. the level reflects the level of renal involvement in acid-base problems.
- D. the level of PSA is elevated in clients in early stage renal failure.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA
A 35-year-old woman one-day postpartum receiving butorphanol tartrate (Stadol) 1 mg IM.
Which of the following actions is MOST important for the nurse to take after administering the medication?
- A. Observe the woman for sedation.
- B. Monitor the vital signs.
- C. Assess for visual disturbances.
- D. Evaluate fluid status.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice and how it relates to Stadol. (1) causes sedation, but not most important (2) correct-decreases rate and depth of respirations (3) diplopia and blurred vision are side effects, but not most important (4) not side effect of medication
The client is to be discharged after passing a uric acid kidney stone. This is the third time the client has been hospitalized for kidney stones. The nurse should teach the client to do which of the following?
- A. Eat generous amounts of chicken and organ meats
- B. Drink lots of water
- C. Avoid vigorous activity
- D. Take the ordered allopurinol (Zyloprim) if the symptoms recur
Correct Answer: B
Rationale: Increased fluid intake (lots of water) prevents stone formation by diluting urine. High-purine foods (meats), activity avoidance, or conditional allopurinol are incorrect.