Nokea
A client is receiving lipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The home care nurse makes a visit and discusses potential side and adverse effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of a suspected adverse effect, which action is the priority?
- A. Stop the infusion.
- B. Contact the nurse.
- C. Take the client's blood pressure.
- D. Contact the local area emergency response team.
Correct Answer: A
Rationale: Signs/symptoms of an adverse effect to lipids (fat emulsion) include chest and back pain, chills, vertigo, cyanosis, diaphoresis, dyspnea, fever, flushing, headache, nausea and vomiting, and thrombophlebitis of the vein. The priority action is to stop the infusion to limit the adverse response. Although contacting the nurse, taking the client's blood pressure, and contacting the local emergency response team are correct interventions, the priority is to stop the infusion.
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The mother of a teenage client diagnosed with an anxiety disorder is concerned about her daughter's progress after discharge. She states that her daughter 'stashes food, eats all the wrong things that make her hyperactive,' and 'hangs out with the wrong crowd.' To assist the mother with preparing for her daughter's discharge, the nurse advises the mother to implement which action in order to promote optimal health?
- A. Restrict the daughter's socializing time with her school friends.
- B. Consider taking time off to help her daughter readjust to the home environment.
- C. Limit the amount of chocolate and caffeine products that are available in the home.
- D. Keep her daughter out of school until she proves that she can adjust to the school environment.
Correct Answer: C
Rationale: Limiting chocolate and caffeine reduces anxiety triggers in clients with anxiety disorders. Restricting socializing, taking time off work, or keeping her out of school are impractical or unhealthy, hindering social and emotional adjustment.
A client is diagnosed with hyperphosphatemia caused by hypoparathyroidism. To prevent worsening of the condition, the nurse should instruct the client to avoid which food selections? Select all that apply.
- A. Fish
- B. Eggs
- C. Coffee
- D. Grapes
- E. Bananas
- F. Whole-grain breads
Correct Answer: A,B,F
Rationale: Food items and liquids that are naturally high in phosphates include fish, eggs, milk products, whole grains, vegetables, and carbonated beverages, and they should be avoided by the client with hyperphosphatemia. Coffee, grapes, and bananas are acceptable for this client to consume because their phosphate levels are not significant.
A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for what period of time?
- A. 1 week
- B. 24 hours
- C. 5 to 7 days
- D. 2 to 3 weeks
Correct Answer: D
Rationale: Levodopa takes 2 to 3 weeks to show results in Parkinson's disease, as it gradually increases dopamine levels to alleviate symptoms. Shorter time frames (24 hours, 5 to 7 days, 1 week) are unrealistic for noticeable improvement.
The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding?
- A. A normal value that indicates that the client is managing blood glucose control well
- B. A value that does not offer information regarding the client's management of the disease
- C. A low value that indicates that the client is not managing blood glucose control very well
- D. A high value that indicates that the client is not managing blood glucose control very well
Correct Answer: D
Rationale: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management 1 to 2 days before the test is done. The glycosylated hemoglobin level should be 6.0% or less for a client diagnosed with diabetes mellitus, with elevated levels indicating poor glucose control.
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
- A. Teaching the client to feel for reddened areas
- B. Asking a family member to assess the skin daily
- C. Teaching the client to use a mirror for skin assessment
- D. Scheduling the client to return to the clinic daily for a skin check
Correct Answer: C
Rationale: The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.