Nokea
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
- A. At least you will still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're lucky to have a wife to care for you.'
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.
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Which of the following is the priority for a client in addisonian crisis?
- A. Controlling hypertension.
- B. Preventing irreversible shock.
- C. Preventing infection.
- D. Relieving anxiety.
Correct Answer: B
Rationale: Addisonian crisis is a life-threatening condition requiring urgent intervention to prevent irreversible shock due to adrenal insufficiency.
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
What is the nurse's best response to a client with Parkinson's experiencing dyskinesia?
- A. Increase medication dose.
- B. Teach relaxation techniques.
- C. Restrict all activity.
- D. Ignore the symptoms.
Correct Answer: B
Rationale: Teaching relaxation techniques can help manage dyskinesia, a side effect of Parkinson's medications.
Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply.
- A. Systolic blood pressure, 145 mm Hg.
- B. Diastolic blood pressure, 87 mm Hg.
- C. High-density lipoprotein (HDL), 30 mg/dL.
- D. Glycosylated hemoglobin (HbA1c), 10.2%.
- E. Triglycerides, 425 mg/dL.
- F. Urine ketones, negative.
Correct Answer: A,C,D,E
Rationale: Systolic hypertension (145 mm Hg), low HDL (30 mg/dL), high HbA1c (10.2%), and elevated triglycerides (425 mg/dL) indicate poor control and cardiovascular risk, requiring reporting. Normal diastolic pressure and negative ketones are not concerning.
Which of the following is a priority outcome for the client with Addison's disease?
- A. Maintenance of medication compliance.
- B. Adherence to a 2-g sodium diet.
- C. Prevention of hypertensive episodes.
- D. Demonstration of effective coping skills.
Correct Answer: A
Rationale: Medication compliance is critical in Addison's disease to prevent adrenal crisis and maintain hormonal balance.