Nokea
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.
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The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
- A. Measuring the urinary output
- B. Checking the vital signs
- C. Encouraging increased fluid intake
- D. Weighing the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.
A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:
- A. In the acutely depressed state
- B. When the depression starts to lift
- C. In the denial phase
- D. During a manic episode
Correct Answer: B
Rationale: When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.
The physician has ordered synthetic thyroid medication for a patient with hypothyroidism. The nurse should instruct the client to:
- A. Take the medication with food to prevent nausea
- B. Take the medication at bedtime
- C. Take the medication in the morning with water
- D. Take the medication with the evening meal
Correct Answer: C
Rationale: Thyroid medication (e.g. levothyroxine) is best taken in the morning on an empty stomach with water to optimize absorption and align with the body’s circadian rhythm. Taking it with food or at other times may reduce efficacy.
A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Call the physician to request a psychological consultation for the client
- C. Turn on the television to distract the client's attention from his amputated leg
- D. Give the client his order of Demerol 50 mg IM prn
Correct Answer: D
Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.