Nokea
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
- A. Fluid restriction
- B. Administering diuretics
- C. Increased sodium intake
- D. Intravenous (IV) replacement of fluid losses
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
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Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
- A. A syringe that contains a preservative
- B. A heparinized syringe and a bag of ice
- C. A heparinized syringe and a preservative
- D. A syringe that contains a preservative and a bag of ice
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
- A. Scheduling weekly follow-up appointments
- B. Establishing contracts with available crisis resources
- C. Encouraging family and friends to be with the client at all times
- D. Providing phone numbers for the hospital and primary health care provider
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
- A. Normal social play that ceases by age 5
- B. Lack of social interaction and awareness
- C. The consistent imitation of others' actions
- D. Normal verbal but abnormal nonverbal communication
Correct Answer: B
Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
- A. Cerebral palsy is an infectious disease of the central nervous system.
- B. Cerebral palsy is an inflammation of the brain as a result of a viral illness.
- C. Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
- D. Cerebral palsy is a congenital condition that results in moderate to severe retardation.
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.