Nokea
A client with a history of a gastrectomy is being taught about dietary management. The nurse should encourage the client to:
- A. Eat six small meals a day
- B. Avoid fluids with meals
- C. Eat high-fiber foods
- D. Take a multivitamin daily
Correct Answer: A
Rationale: After a gastrectomy, eating six small meals a day prevents dumping syndrome by reducing gastric overload. Avoiding fluids with meals and taking vitamins are helpful, but small meals are primary.
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A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Smooth, coordinated voluntary movement
- B. Tremors
- C. Rigidity
- D. Muscle weakness
Correct Answer: A
Rationale: Benztropine alleviates extrapyramidal side effects of tranquilizers, such as tremors and rigidity, resulting in smooth, coordinated movements.
Which of the following describes a positive Kernig's sign?
- A. Pain on flexion of the hip and knee
- B. Nuchal rigidity on flexion of the neck
- C. Pain when the head is turned to the left side
- D. Dizziness when changing positions
Correct Answer: A
Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.
The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client's urine output pattern as:
- A. Anuria
- B. Oliguria
- C. Dysuria
- D. Polyuria
Correct Answer: D
Rationale: Polyuria is a primary symptom of diabetes insipidus. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and sodium increases.
A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
- A. Hyperammonemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.
The client is admitted with a diagnosis of gestational diabetes. Which fetal monitoring technique is most appropriate?
- A. Non-stress test
- B. Biophysical profile
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Gestational diabetes increases fetal risks (e.g. macrosomia hypoglycemia) requiring close monitoring. Non-stress tests assess fetal heart rate and biophysical profiles evaluate fetal well-being comprehensively. Both are appropriate.