Nokea
A client with a traumatic brain injury is receiving mannitol. The nurse should monitor for which adverse effect of this medication?
- A. Hypotension
- B. Hyperkalemia
- C. Hyperglycemia
- D. Bradycardia
Correct Answer: A
Rationale: Mannitol, an osmotic diuretic, can cause hypotension (A) from fluid shifts and diuresis. Hyperkalemia (B), hyperglycemia (C), or bradycardia (D) are less common. A is correct. Rationale: BP drop risks perfusion; monitoring ensures safety, per pharmacology, critical in brain injury management.
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The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
- A. Is asleep 30 minutes after the injection
- B. Asks for extra servings on his meal tray
- C. Has an increased urinary output
- D. States that he is feeling less nauseated
Correct Answer: A
Rationale: Being asleep 30 minutes post-Stadol indicates effective pain relief and sedation, its intended effect post-op extra food, urine output, or less nausea aren't primary goals. Nurses monitor response, ensuring rest and pain control, critical for recovery in surgical care.
Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
- A. Encouraging frequent changes in position
- B. Applying heat packs to stiff joints
- C. Administering muscle relaxants
- D. Using soft restraints to immobilize the extremities
Correct Answer: A
Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
This is also known as Self-suggestion or Self-hypnosis
- A. Biofeedback
- B. Meditation
- C. Autogenic training
- D. Visualization and Imagery
Correct Answer: C
Rationale: Autogenic training (C) is self-suggestion or self-hypnosis, using phrases to induce relaxation (e.g., 'my arms are heavy'). Biofeedback (A) relies on machines, meditation (B) on focus, and visualization (D) on imagery not self-hypnosis. Autogenic training, per Schultz, shifts autonomic responses via mental cues, aligning with the definition, making C correct.