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A client with a moderate level of anxiety is pacing quickly in the hall. As the nurse approaches, he states, 'Help me. I can't take it anymore.' Which of the following would be the best response initially?
- A. It would be best if you would lie down until you're calmer.'
- B. Let's go to a quieter area where we can talk if you want.'
- C. Try doing your relaxation exercises to calm down.'
- D. I'll get some medicine to help you relax.'
Correct Answer: B
Rationale: Offering to talk in a quieter area de-escalates anxiety and provides a supportive environment.
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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).
When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
Older adults with known cardiovascular disease must balance which of the following measures for optimum health?
- A. Diet, exercise, and medication.
- B. Stress, hypertension, and pain.
- C. Mental health, diet, and stress.
- D. Social events, diet, and smoking.
Correct Answer: A
Rationale: Diet, exercise, and medication are critical for managing cardiovascular disease, as they address risk factors like cholesterol, physical fitness, and blood pressure control, directly impacting heart health.
A client with a history of tuberculosis is prescribed isoniazid (INH). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Isoniazid can cause hepatotoxicity, requiring regular liver function monitoring.
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding phosphate in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sevelamer binds phosphate in the gut, reducing serum phosphate levels in chronic kidney disease.