Nokea
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Check the client's level of consciousness
- B. Obtain the regular blood glucose readings
- C. Determine if special skin care is needed
- D. Answer questions from the client's spouse about the plan of care
Correct Answer: B
Rationale: The UAP can safely obtain blood glucose readings, which are routine tasks.
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Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: The belief that every person is worthy of dignity and respect is foundational to psychiatric mental health nursing, emphasizing client-centered care. The other options are also relevant but not the primary belief highlighted here. Psychosocial Integrity
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
A patient who sustained massive internal injuries in a car crash becomes hypotensive and develops acute renal failure.
Which acid-base imbalance is he most likely to experience?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: Renal failure causes metabolic acidosis due to impaired acid excretion.
A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.
Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic neuropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct Answer: C
Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.