Nokea
A nurse has received a report on a group of clients. Which of the following client clients should the nurse assess first?
- A. A client who has type 2 diabetes mellitus has a blood glucose level of 120 mg/dL (74 - 106 mg/dL)
- B. A client who has diabetes insipidus has an intake of 1,500 mL and an output of 1,600 mL in 24 hr.
- C. A client who has Graves' disease has a heart rate of 100/min and reports tremors.
- D. A client who has a left-sided stroke reports severe headache and is manifesting confusion.
Correct Answer: D
Rationale: The correct answer is D. A client with a left-sided stroke reporting severe headache and confusion should be assessed first due to the potential risk of worsening neurological status. Headache and confusion could indicate a worsening condition such as hemorrhage or increased intracranial pressure, requiring immediate intervention to prevent further damage. Assessing this client first allows for prompt treatment and prevention of complications. Choices A, B, and C involve clients with chronic conditions or stable vital signs that do not indicate immediate danger. Assessing the client with a left-sided stroke takes priority over these cases due to the acute nature of the symptoms.
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A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
Administer heparin 1000 units per hour IV. The pharmacy supplies the heparin infusion as 25.000 units in 500 mL DSW. What will the IV pump be set to? (Include unit of measure with answer).
Correct Answer: 20
Rationale: To calculate the IV pump rate, first determine the number of units needed per mL: 25,000 units / 500 mL = 50 units per mL. Then, divide the prescribed rate of 1000 units per hour by the units per mL to get the pump setting: 1000 units / 50 units per mL = 20 mL per hour. Therefore, the correct answer is 20 mL/hour.
Incorrect choices:
A: Incorrect, doesn't follow the correct calculation method.
B: Incorrect, doesn't consider the units per mL.
C: Incorrect, doesn't involve the prescribed rate.
D: Incorrect, doesn't calculate the infusion rate.
E: Incorrect, lacks the necessary calculation steps.
F: Incorrect, doesn't relate to the given information.
G: Incorrect, doesn't follow the correct calculation process.
A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate the client is experiencing maladaptive grief?
- A. The client meets his daughter for dinner every week.
- B. The client joined a bowling league 2 months ago.
- C. The client exercises at a local health facility 3 days each week.
- D. The client has kept his partner's closet untouched since her death.
Correct Answer: D
Rationale: The correct answer is D because keeping the partner's closet untouched after five years indicates a lack of acceptance and inability to move forward in the grieving process, suggesting maladaptive grief. Choice A shows social support, B reflects engagement in a new activity, and C indicates a healthy coping mechanism through exercise.
Which of the following is a risk factor for shaken baby syndrome?
- A. Low socioeconomic status
- B. Inadequate parental education
- C. Having multiple siblings
- D. Physical disability of the caregiver
Correct Answer: A
Rationale: The correct answer is A: Low socioeconomic status. Low socioeconomic status can lead to increased stress levels and lack of access to resources, increasing the likelihood of caregiver frustration and potential for shaken baby syndrome. Inadequate parental education (B) may contribute, but is not as directly linked. Having multiple siblings (C) and physical disability of the caregiver (D) are not direct risk factors for shaken baby syndrome.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Confusion
- B. Fatigue
- C. Pain
- D. Slurred speech
Correct Answer: B
Rationale: The correct answer is B: Fatigue. In iron deficiency anemia, the body lacks enough iron to produce hemoglobin, leading to decreased oxygen delivery to tissues, resulting in fatigue. Confusion (A) is not a typical finding. Pain (C) is not a direct symptom of iron deficiency anemia. Slurred speech (D) is more commonly associated with neurological conditions. In summary, fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen delivery, making it the expected finding.