Nokea
A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?
- A. Give him written material from the American Heart Association about sexual activity with heart disease
- B. Answer his questions accurately in a private environment
- C. Schedule a private, uninterrupted teaching session with both the client and his wife
- D. Assess the client's knowledge about his health problems
Correct Answer: D
Rationale: The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.
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The nurse is caring for a client with a history of myocardial infarction.
- A. Which instruction is most important for a client post-myocardial infarction?
- B. Avoid heavy lifting for 6 weeks.
- C. Take nitroglycerin only when chest pain occurs.
- D. Resume normal activity immediately.
- E. Monitor blood pressure weekly.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units subcutaneously at bedtime. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 100 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and irritability.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and irritability indicate hypoglycemia, a serious complication of insulin glargine, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 100 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
- A. Report changes in urinary pattern.
- B. Allow six weeks for optimal effects.
- C. Increase the amount of carbohydrates in your diet.
- D. Use lotions to treat itching.
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .
A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Her mother is a type I diabetic.
The nurse knows the infant is at GREATest risk for developing
- A. hypovolemia.
- B. hypoglycemia.
- C. hyperglycemia.
- D. cold stress.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice. (1) no change in blood volume for infant of diabetic mother (2) correct-fetus produces increased insulin to match mother's increased glucose level during pregnancy, infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment, increases metabolic rate, infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes, not expected with diabetic mother
The nurse is to remove an indwelling urinary catheter from an adult client. Which step should be done first?
- A. Cut the catheter with scissors.
- B. Withdraw the fluid from the balloon.
- C. Clamp the catheter.
- D. Remove the catheter.
Correct Answer: B
Rationale: Withdrawing fluid from the balloon deflates it, allowing safe catheter removal without urethral trauma. Cutting, clamping, or pulling without deflation risks injury.