Nokea
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
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Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Solu medrol
Correct Answer: A
Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic
- B. Obtain an ice bag and apply to the client's throat
- C. Turn the client to one side
- D. Notify the physician
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a risk in CVA patients with nausea due to impaired swallowing or consciousness. This is the priority before other actions.
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.
- A. check the dressing every 8 hours for excessive drainage
- B. assess the pupils for signs of increased intracranial pressure
- C. position the client flat with the head rotated away from the surgical site
- D. monitor the client's respiratory status, including rate and pattern of breathing
- E. notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Correct Answer: B, D, E
Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.