Nokea
A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?
- A. Polyphagia
- B. Polyuria
- C. Metabolic acidosis
- D. Lower extremity edema
Correct Answer: D
Rationale: Polyphagia, polyuria, and metabolic acidosis are common clinical signs of diabetes mellitus. Polyphagia refers to excessive hunger, polyuria is excessive urination, and metabolic acidosis can occur due to poorly controlled diabetes. Lower extremity edema, on the other hand, is not a typical clinical sign of diabetes mellitus. Edema in the lower extremities is more commonly associated with conditions like heart failure or kidney disease rather than diabetes mellitus.
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During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?
- A. Contact the patient's physician immediately
- B. Recommend the patient lie on his right side
- C. Advise the patient to schedule a doctor's visit the next day
- D. Suggest holding the drug Azmacort
Correct Answer: A
Rationale: The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.
A healthcare professional is reviewing a patient's serum glucose levels. Which of the following scenarios would indicate abnormal serum glucose values for a 30-year-old male?
- A. 70 mg/dL
- B. 55 mg/dL
- C. 110 mg/dL
- D. 100 mg/dL
Correct Answer: B
Rationale: The correct answer is 55 mg/dL. The standard range for serum glucose levels is typically 60-115 mg/dL. A serum glucose level of 55 mg/dL falls below this range, indicating hypoglycemia. Options A, C, and D are within the standard range for serum glucose levels and would not be considered abnormal for a 30-year-old male.
A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:
- A. is given after the D10W is finished.
- B. should be given at the time it is due in the medication port closest to the client.
- C. can be piggybacked into the D10W solution now.
- D. is incompatible with dextrose solutions.
Correct Answer: D
Rationale: Phenytoin is incompatible with dextrose solutions as they will precipitate when mixed together. Therefore, it should not be piggybacked into the D10W solution or given through the same port. Instead, normal saline should be used to flush before and after administering phenytoin to prevent any interaction with the dextrose solution. Delaying the administration of an antiepileptic drug like phenytoin to maintain therapeutic blood levels is not recommended, so it should not be given after the D10W is finished or based on the medication port closest to the client. Choice A is incorrect because administering phenytoin after the D10W is finished is not the correct approach due to the incompatibility with dextrose solutions. Choice B is incorrect as the timing of phenytoin administration should not be based on the medication port closest to the client but on compatibility considerations. Choice C is incorrect as piggybacking phenytoin into the D10W solution is not advisable due to the incompatibility issue.
A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.
Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial to ensure that the client is not only breathing but also breathing adequately. Choices A and D are incorrect as pulse rate and patient position are not the most critical observations when assessing a client's breathing. Pulse rate is more related to assessing circulation, and patient position is important but not as crucial as ensuring the client is breathing and breathing adequately. Choice B is partially correct as breathing pattern is important, but the most critical observation is the adequacy of breathing. Adequacy of breathing ensures that the client is receiving enough oxygen to support proper body function and is the key focus during breathing assessment.