Nokea
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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What is the correct intervention for a patient experiencing anaphylaxis?
- A. Administer epinephrine
- B. Provide oxygen
- C. Monitor airway
- D. All of the above
Correct Answer: D
Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.
A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?
- A. Use the cane on the stronger side
- B. Advance the cane and the weaker leg at the same time
- C. Use the cane on the weaker side
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.
How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct Answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?
- A. Urinary catheters
- B. Indwelling catheters
- C. Sterile gloves
- D. Sterile gowns
Correct Answer: A
Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.
Which instruction should be emphasized for a client with diabetes being discharged?
- A. Check blood sugar once daily
- B. Take insulin before meals as prescribed
- C. Monitor glucose levels weekly
- D. Eat carbohydrate-rich meals to maintain glucose levels
Correct Answer: B
Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.