Nokea
A client is admitted with pernicious anemia. The client reports all of the following. Which is most likely related to the admitting diagnosis?
- A. I often have diarrhea.'
- B. My tongue is more red and thick than usual.'
- C. I have little bruise-like spots on my arms and legs.'
- D. I have been running a fever for the last two days.'
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes a sore, red, beefy tongue. Diarrhea, bruising, or fever are less specific.
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A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
- A. asking whether another individual wants to be her support person
- B. assuring her that the nursing triage group will be with her at all times
- C. telling her you will try to locate her family
- D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
Correct Answer: A
Rationale: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.
A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- A. Repeat glycohemoglobin in 24 hours
- B. Document Accu-checks, intake and output every 4 hours
- C. Humulin N 20 units IV push
- D. IV fluids of 0.9% normal saline at 125 ml per hour
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.
The nurse is responsible for teaching the client regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium?
- A. Apple
- B. Spinach
- C. Liver
- D. Squash
Correct Answer: B
Rationale: Spinach is a rich source of magnesium, found in green leafy vegetables, nuts, and whole grains. Apple , liver , and squash have lower magnesium content.