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A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
- A. Check the client's blood glucose level.
- B. Administer 10 units of insulin.
- C. Give the client a high-protein snack.
- D. Measure the client's blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Check the client's blood glucose level. The client's symptoms are indicative of hypoglycemia, which is a common complication in diabetes mellitus. Checking the blood glucose level will confirm the diagnosis and guide appropriate interventions. Administering insulin (B) could worsen the hypoglycemia. Giving a high-protein snack (C) may help raise blood sugar levels but should be done after confirming the diagnosis. Measuring blood pressure (D) is not the priority in this situation.
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The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?
- A. Hemoglobin level of 12 g/dL.
- B. Platelet count of 150,000/mm3.
- C. White blood cell count of 2,000/mm3.
- D. Serum creatinine level of 1.0 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Hyperactivity
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Risperidone is an atypical antipsychotic medication known to cause metabolic side effects such as hyperglycemia. The nurse should monitor the client for signs and symptoms of high blood sugar levels, such as increased thirst, frequent urination, and fatigue. Hypertension (choice A) is not a common side effect of risperidone. Weight loss (choice B) is less likely as risperidone is associated with weight gain. Hyperactivity (choice C) is not a typical side effect of risperidone. Therefore, monitoring for hyperglycemia is essential in clients taking risperidone.
An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct Answer: C
Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale:
1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior.
2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact.
3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue.
4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being.
In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.
A client with Addison's disease is being treated with fludrocortisone (Florinef). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hypernatremia. Fludrocortisone is a mineralocorticoid that promotes sodium retention and potassium excretion, leading to an increase in sodium levels. Addison's disease involves low levels of cortisol and aldosterone, so fludrocortisone is used to replace aldosterone. Monitoring for hypernatremia is crucial to prevent complications like hypertension and fluid retention. Hyperkalemia (A) is not expected due to the drug's potassium-excreting effect. Hyponatremia (B) is unlikely as the drug promotes sodium retention. Hypocalcemia (D) is not directly related to fludrocortisone therapy.
A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?
- A. Administer morphine sulfate.
- B. Place the client in a high Fowler's position.
- C. Initiate continuous ECG monitoring.
- D. Prepare the client for intubation.
Correct Answer: B
Rationale: The correct action for the nurse to take first is to place the client in a high Fowler's position (Choice B). This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and improving ventilation. With severe shortness of breath and pink, frothy sputum, the priority is to optimize respiratory function. Administering morphine sulfate (Choice A) may be indicated later for pain and anxiety but is not the immediate priority. Initiating continuous ECG monitoring (Choice C) is important but not as urgent as addressing the respiratory distress. Preparing the client for intubation (Choice D) should be considered if respiratory distress worsens, but initial interventions should focus on improving oxygenation through positioning.