Nokea
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
- A. Deficient fluid volume related to osmotic diuresis
- B. Decreased cardiac output related to increased heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.
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Management of hypercalcemia includes all of the following actions except administration of:
- A. Fluid to dilute the calcium le⁺vels
- B. The diuretic furosemide (Lasix), without saline, to increase calcium excretion through kidneys
- C. Inorganic phosphate salts
- D. Intravenous phosphate therapy
Correct Answer: B
Rationale: The correct answer is B because administration of the diuretic furosemide without saline is not recommended for managing hypercalcemia. Furosemide can lead to volume depletion and potentially exacerbate hypercalcemia by concentrating calcium levels in the blood.
A: Fluid administration helps dilute calcium levels by increasing urine output.
C: Inorganic phosphate salts can bind with calcium in the gut, reducing absorption.
D: Intravenous phosphate therapy can help lower calcium levels by promoting calcium-phosphate complex formation.
In summary, B is incorrect as it may worsen hypercalcemia, while A, C, and D are valid strategies for managing hypercalcemia.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
- A. “I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear.”
- B. “I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal.”
- C. “I will receive parenteral vitamin B12 therapy monthly for 6 months to a year.”
- D. “I will receive parenteral vitamin B12 therapy for the rest of my life.”
Correct Answer: D
Rationale: The correct answer is D: “I will receive parenteral vitamin B12 therapy for the rest of my life.” This statement is correct because pernicious anemia is a lifelong condition requiring ongoing vitamin B12 supplementation. Patients with pernicious anemia lack intrinsic factor, which is needed to absorb vitamin B12 from food. Therefore, they need lifelong B12 therapy to prevent complications such as anemia and neurological damage.
Choices A, B, and C are incorrect because they suggest a limited duration of therapy. Pernicious anemia is a chronic condition that necessitates continuous treatment. Choice A implies therapy until signs and symptoms disappear, which may not address the underlying cause of the deficiency. Choice B mentions therapy until vitamin B12 levels normalize, which may not prevent recurrence. Choice C suggests monthly therapy for a fixed period, which may not be sufficient for lifelong management.
Which virus causes genital warts?
- A. Cytomegalovirus
- B. Human papillomavirus
- C. Herpes simplex virus type II
- D. Human immunodeficiency virus
Correct Answer: B
Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the virus that causes genital warts. It is transmitted through sexual contact and is the most common sexually transmitted infection. Cytomegalovirus (A) does not cause genital warts. Herpes simplex virus type II (C) causes genital herpes, not warts. Human immunodeficiency virus (D) causes AIDS and weakens the immune system but does not directly cause genital warts.
Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
- A. Shampoo hair thoroughly to remove oil and dirt
- B. No special preparation is needed. Instruct the patient to keep his head still and stead
- C. Give a cleansing enema and give fluids until 8 AM
- D. Shave scalp and securely attach electrodes to it
Correct Answer: A
Rationale: The correct answer is A because shampooing the hair thoroughly helps remove oil and dirt, which can interfere with the CT scan results. By having clean hair, the scan can produce clearer images.
Choice B is incorrect because some preparation is needed for a CT scan, especially regarding cleanliness.
Choice C is incorrect as giving a cleansing enema and fluids until 8 AM is not necessary for a CT scan of the head.
Choice D is incorrect as shaving the scalp and attaching electrodes are not part of routine preparation for a CT scan.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.