Nokea
A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: A
Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.
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A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.
Which one of the following situations represents a maturational crisis for the family?
- A. A four-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
The nurse is caring for a client with a diagnosis of postpartum hemorrhage. Which vital sign change is most likely to be observed?
- A. Tachycardia
- B. Hypotension
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Postpartum hemorrhage causes significant blood loss leading to tachycardia (to compensate for reduced volume) and hypotension (from decreased perfusion). Both are common vital sign changes.
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
Correct Answer: C
Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.
What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
- A. Human chorionic gonadotropin
- B. Estrogen
- C. α-fetoprotein
- D. Sphingomyelin
Correct Answer: A
Rationale: Human chorionic gonadotropin is the biochemical basis for pregnancy tests, produced by the placenta to maintain the corpus luteum.