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A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Monitor the client's blood glucose level.
- B. Encourage the client to increase fluid intake.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: A
Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.
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The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
- A. Leave the order for the oncoming staff to follow up
- B. Contact the charge nurse for an interpretation
- C. Ask the pharmacy for assistance in interpretation
- D. Call the provider for clarification
Correct Answer: D
Rationale: The nurse should call the provider for clarification. In situations where there is difficulty reading an order, it is crucial to directly contact the healthcare provider to ensure the correct order is understood and followed. Leaving the order for the oncoming staff (Choice A) may lead to misunderstandings and errors. Contacting the charge nurse (Choice B) may cause delays as they may also need to contact the provider. Asking the pharmacy (Choice C) is not the most direct and immediate action in this scenario, as the provider is the one who can provide immediate clarification.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?
- A. Directly address the child instead of the mother.
- B. Continue asking the mother questions about the child.
- C. Request another nurse to interview the mother now.
- D. Politely ask the mother to look at you when answering.
Correct Answer: B
Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.
A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct Answer: B
Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
- A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
- B. Pinch the skin on the back of the hand and observe for elasticity
- C. Assess the skin turgor on the abdomen by pinching the skin
- D. Check the skin turgor by pressing on the forearm and observing the rebound
Correct Answer: A
Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.
A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
- A. Concave thoracic spine posteriorly
- B. Exaggerated lumbar curvature
- C. Concave lumbar spine posteriorly
- D. Exaggerated thoracic curvature
Correct Answer: B
Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.