Nokea
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypophosphatemia.
- D. Hypermagnesemia.
- E. Hypocalcemia.
Correct Answer: A, C
Rationale: Diabetic ketoacidosis can cause hypokalemia (insulin shifts potassium) and hypophosphatemia (osmotic diuresis).
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The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys are appropriate for her child. Which of the following should the nurse suggest?
- A. Picture books
- B. Peek-a-boo
- C. Rattle
- D. Colored blocks
Correct Answer: B
Rationale: Peek-a-boo is an age-appropriate activity for a 7-month-old, promoting social and cognitive development. Picture books and colored blocks are better for older children, and a rattle may be less engaging for this age.
The nurse is teaching a client with a new diagnosis of hypertension about medication adherence. Which of the following statements by the client indicates a need for further teaching?
- A. I'll take my medication every morning.'
- B. I'll check my blood pressure regularly.'
- C. I'll stop my medication if I feel fine.'
- D. I'll avoid high-sodium foods.'
Correct Answer: C
Rationale: Stopping medication when feeling fine indicates a misunderstanding, as hypertension requires ongoing treatment.
A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply.
- A. Hypotension.
- B. Bradycardia.
- C. Seizures.
- D. Profound pyrexia.
- E. Hypertension.
Correct Answer: C, D, E
Rationale: Sympathomimetic overdose can cause seizures, profound pyrexia (fever), and hypertension due to excessive stimulation of the sympathetic nervous system.
Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this 'gate' to pain are low endorphins and anxiety and that some of the factors that close this 'gate' to pain are decreased anxiety and fear?
- A. Moritz Schiff's theory of pain
- B. The Intensive Theory of Pain
- C. Melzack and Wall's theory of pain
- D. The Specificity Theory of Pain
Correct Answer: C
Rationale: Melzack and Wall's Gate Control Theory posits that pain perception is modulated by factors like anxiety (opening the gate) and reduced anxiety or endorphins (closing the gate).
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.