Nokea
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The signs and symptoms of headache, sweating, tremor, pallor, and nervousness described in the client suggest hypoglycemia, which is caused by low blood sugar levels. Insulin is a medication used to lower blood sugar levels in individuals with diabetes. In this case, the client has taken a combination of regular insulin and NPH insulin before breakfast, which could have led to a rapid drop in blood sugar levels by the afternoon causing the symptoms described. It is important to treat hypoglycemia promptly by giving the client a fast-acting carbohydrate source, such as glucose tablets or juice, to raise their blood sugar back to a safe level.
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The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. What is the nurse's best response?
- A. Blood pressure will stabilize.
- B. The child will have more energy.
- C. Urine will be free of protein.
- D. Urinary output will increase.
Correct Answer: D
Rationale: In acute glomerulonephritis, the kidneys are inflamed and not functioning properly, leading to a decrease in urinary output. As the condition improves, the kidneys are able to filter and excrete waste products more effectively, resulting in an increase in urinary output. This is the first indication that acute glomerulonephritis is improving because it shows that the kidneys are starting to function better. Blood pressure stabilization, increased energy, and absence of protein in the urine may also be positive signs of improvement, but an increase in urinary output is the most direct and specific indicator of improved kidney function in this context.
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn't drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it'll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
- A. Negative Coombs test
- B. Bleeding from the nose and ear
- C. Jaundice after the first 24 hours of life
- D. Jaundice within the first 24 hours of life
Correct Answer: D
Rationale: A neonate born to a mother with blood type AB and a father with blood type O is at risk for ABO blood incompatibility, particularly if the neonate is blood type A or B. The major sign of ABO blood incompatibility in the neonate is the development of jaundice within the first 24 hours of life. This occurs due to the mismatch in blood types between the mother and the neonate, leading to the destruction of the neonate's red blood cells. This destruction releases bilirubin, causing jaundice. It is important to note that unlike Rh incompatibility, ABO incompatibility usually does not lead to severe complications requiring treatment. A positive Coombs test result is not typically seen in ABO blood incompatibility.
The patient asks the nurse, "What is hypertension?" Which of the following is the best response to explain hypertension?
- A. "It is measured as the heart pumps blood into the arteries."
- B. "It is higher than normal on two separate occasions."
- C. "It is regulated by stress, activity, and emotions."
- D. "It is determined by peripheral vascular resistance."
Correct Answer: B
Rationale: Hypertension, also known as high blood pressure, is a condition where the force of blood against the walls of the arteries is consistently too high. The definition provided in choice B, "It is higher than normal on two separate occasions," accurately captures the concept of hypertension. A diagnosis of hypertension typically requires blood pressure measurements to be consistently elevated on at least two separate occasions to rule out temporary spikes in blood pressure. This distinction is essential in diagnosing and managing hypertension effectively to prevent complications such as heart disease, stroke, and kidney problems. Choices A, C, and D do not capture the defining characteristic of hypertension as clearly as choice B.