Nokea
A client with a diagnosis of diabetes insipidus asks the nurse about the purpose of the vasopressin she has been prescribed. The nurse responds, knowing that this medication promotes which action?
- A. Vasodilation
- B. Decrease in peristalsis
- C. Decrease in urinary output
- D. Inhibit smooth muscle contraction
Correct Answer: C
Rationale: Vasopressin is a vasopressor and an antidiuretic. It directly stimulates contraction of smooth muscle, causes vasoconstriction, stimulates peristalsis, and increases reabsorption of water by the renal tubules, resulting in decreased urinary output.
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During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
- A. 4,2,1
- B. 4,1,5
- C. 4,5,1
- D. 4,2,5
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
A client with type 1 diabetes mellitus asks the nurse whether he can take ginseng at home. The nurse should tell the client:
- A. No, there are no therapeutic benefits of ginseng
- B. You can take the ginseng to help improve your memory
- C. You can take ginseng if you take it with a carbohydrate
- D. You should ask your physician, as ginseng may affect blood sugar levels
Correct Answer: D
Rationale: Ginseng may affect blood sugar levels, potentially interacting with diabetes management, so the client should consult their physician. Ginseng has potential benefits but requires caution in diabetes.
Your client is receiving phototherapy. What nursing intervention would you implement for this client?
- A. Placing the client in the Trendelenburg position
- B. Monitoring the color of the stools
- C. Using a Hoyer lift for patient transfers
- D. Monitoring the arterial blood gases
Correct Answer: B
Rationale: Phototherapy, often used for jaundice, can affect stool color (e.g., green or loose stools in infants). Monitoring stool color helps assess treatment effects and complications.
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
- A. Epidural catheter
- B. Hickman catheter
- C. Central venous catheter (CVC)
- D. Patient-controlled analgesia (PCA) pump
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.