Nokea
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Insist that she remain at the table and eat a balanced diet.
- B. Order a high-calorie diet with supplements.
- C. Provide nutritious finger foods several times a day.
- D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
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Which person is at greatest risk for developing Lyme disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent outdoor exposure in areas where ticks, which transmit the disease, are prevalent.
Which of the following side effects is associated with androgen therapy?
- A. Gynecomastia
- B. Increased appetite
- C. Virilization
- D. Euphoria
Correct Answer: C
Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:
- A. Eat large meals
- B. Avoid caffeine
- C. Lie down after meals
- D. Eat high-fat foods
Correct Answer: B
Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.
The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
- A. Evaluation process
- B. Objective information
- C. Subjective information
- D. Complaining
Correct Answer: C
Rationale: Subjective information is provided by a person.