Nokea
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?
- A. Restriction of caloric intake.
- B. Fewer fingerstick glucose checks.
- C. Higher doses of insulin.
- D. Increased oral fluid intake.
Correct Answer: C
Rationale: Higher doses of insulin are needed to overcome increased insulin resistance caused by the infection and stress hormones, preventing hyperglycemia and ketoacidosis.
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A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
- A. Rocky Mountain spotted fever.
- B. Intracerebral hemorrhage.
- C. Cerebrovascular accident (CVA).
- D. Meningococcal meningitis.
Correct Answer: D
Rationale: Meningococcal meningitis is characterized by severe headache, fever, nuchal rigidity, and a petechial rash, which are consistent with the client's symptoms.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decrease in output is critical to detect urinary retention or obstruction, potential complications of TUNA.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing the radiation site with antibacterial soap and water can cause dryness, inflammation, and infection, indicating a need for further teaching on using mild soap or saline.
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Obtain a soft diet for the client.
- B. Encourage frequent mouth care.
- C. Cleanse the tongue and mouth with swabs.
- D. Administer a topical analgesic per protocol.
Correct Answer: B
Rationale: Encouraging frequent mouth care is the best initial action to prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris, and moisturizing the oral tissues.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.