Nokea
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
- A. Herbals can interfere with the action of antiviral medication
- B. Supplements have proven effective in prolonging life
- C. Herbals have been shown to decrease the viral load
- D. Supplements appear to prevent replication of the virus
Correct Answer: A
Rationale: Echinacea may interact with antiretroviral medications, potentially reducing their effectiveness.
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A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. confused with cold, clammy skin and a pulse of 110.
- B. lethargic with hot, dry skin and rapid, deep respirations.
- C. alert and cooperative with a BP of 130/80 and respirations of 12.
- D. short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
- A. Keep the room darkened by pulling the curtains
- B. Keep the light over the bed on at all times
- C. Keep the room quiet and dim the lights
- D. Keep the television or radio turned on
Correct Answer: C
Rationale: A quiet, dimly lit room reduces sensory stimulation, decreasing the risk of seizures and hallucinations during alcohol withdrawal.
The nurse is caring for a 28-year-old female with a long history of heroin addiction. The client tells the nurse that she started off using a small amount recreationally, but as time went on, she needed more and more heroin to feel a high. The nurse recognizes this as
- A. addiction.
- B. dependence.
- C. tolerance.
- D. withdrawal.
Correct Answer: C
Rationale: Tolerance is the need for increasing doses to achieve the same effect, as described in the client’s heroin use.
A client confides in the nurse that a close friend recently died from pancreatic cancer. The client asks what the risk factors are for pancreatic cancer. The nurse should respond with
- A. Being a female of Asian descent is linked to an increased risk of pancreatic cancer.'
- B. Drinking two or fewer alcoholic beverages per week is linked to an increased risk of pancreatic cancer.'
- C. Past history of acute pancreatitis before age 20 is linked to an increased risk of pancreatic cancer.'
- D. Cigarette smoking is linked to an increased risk for pancreatic cancer.'
Correct Answer: D
Rationale: Cigarette smoking is a well-established risk factor for pancreatic cancer, increasing risk through carcinogenic exposure.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- A. Impaired physical mobility related to decreased endurance
- B. Hypothermia r/t decreased metabolic rate
- C. Disturbed thought processes r/t interstitial edema
- D. Decreased cardiac output r/t bradycardia
Correct Answer: D
Rationale: Bradycardia in hypothyroidism can lead to decreased cardiac output, which is life-threatening and thus the highest priority diagnosis.