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A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Increased speech
- B. Lack of sleep
- C. Agitation
- D. Poor concentration
Correct Answer: B
Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.
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When providing discharge teaching to a client with diabetes, what is the most important instruction?
- A. Check blood sugar levels once daily
- B. Administer insulin as prescribed before meals
- C. Take medication only when feeling unwell
- D. Eat carbohydrate-rich meals to stabilize blood sugar
Correct Answer: B
Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.
What are the nursing interventions for a patient with hypokalemia?
- A. Administer potassium supplements and monitor ECG
- B. Provide a high-sodium diet and monitor for hypertension
- C. Monitor for muscle weakness and provide dietary education
- D. Administer diuretics and provide oral fluids
Correct Answer: A
Rationale: The correct intervention for a patient with hypokalemia is to administer potassium supplements and monitor the ECG. Potassium supplements help correct the low potassium levels in the body, while ECG monitoring is essential to detect any cardiac arrhythmias associated with hypokalemia. Choice B is incorrect because a high-sodium diet would worsen hypokalemia by further depleting potassium levels. Choice C is incorrect as it only focuses on monitoring symptoms and providing dietary education, but does not address the immediate need to correct potassium levels. Choice D is also incorrect as administering diuretics would exacerbate hypokalemia by increasing potassium loss.
A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct Answer: B
Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.
What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?
- A. Monitor for changes in level of consciousness
- B. Check for pupil dilation
- C. Assess for bradycardia
- D. Monitor for vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?
- A. Prepare a new dose of insulin injection
- B. Administer the insulin as it is
- C. Wipe the needle with an alcohol swab
- D. Ask the provider for guidance
Correct Answer: A
Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.