Nokea
A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.
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The nurse is caring for an 80-year-old client with Parkinson’s disease.
- A. What is the most realistic and appropriate nursing goal for an 80-year-old client with Parkinson’s disease?
- B. Return the client to usual activities of daily living.
- C. Maintain optimal function within the client’s limitations.
- D. Prepare the client for a peaceful and dignified death.
- E. Arrest progression of the disease process in the client.
Correct Answer: B
Rationale: Parkinson’s disease is progressive and irreversible, so maintaining optimal function within the client’s limitations is the most realistic goal, focusing on mobility, safety, and quality of life. Returning to normal activities, preparing for death, or arresting progression are unrealistic or inappropriate.
The nurse is caring for a client with a history of renal failure.
- A. Which laboratory finding is most concerning for a client with chronic renal failure?
- B. Serum creatinine of 2.5 mg/dL.
- C. Serum potassium of 6.2 mEq/L.
- D. Blood urea nitrogen of 30 mg/dL.
- E. Hemoglobin of 10.5 g/dL.
Correct Answer: B
Rationale: A serum potassium of 6.2 mEq/L indicates hyperkalemia, a life-threatening condition in renal failure due to impaired excretion, risking cardiac arrhythmias. Elevated creatinine, BUN, and low hemoglobin are expected but less urgent.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin glargine (Lantus). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should not mix this insulin with other insulins.
- C. I should rotate injection sites.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin glargine when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, it should not be mixed, and rotation prevents lipodystrophy.
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
- A. Prepare the client for a return to surgery.
- B. Apply traction to the urethral catheter.
- C. Document the findings as normal.
- D. Decrease the client's oral fluid intake.
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.