Nokea
A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?
- A. Urine for specific gravity
- B. For the presence of edema
- C. Urine for glucose and ketones
- D. Blood pressure, pulse, and respirations
Correct Answer: C
Rationale: In a pregnant client with diabetes mellitus, assessing insulin function is critical to ensure glycemic control and prevent complications. Testing urine for glucose and ketones is the best assessment, as it directly indicates whether insulin is effectively managing blood glucose levels (glucose in urine suggests hyperglycemia) and whether the client is at risk for ketoacidosis (ketones indicate fat metabolism due to insufficient insulin). Urine specific gravity reflects hydration status, not insulin function. Edema assessment is relevant for preeclampsia or fluid overload, not insulin function. Vital signs like blood pressure, pulse, and respirations provide general health information but are not specific to insulin function.
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A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
- A. Bruising behind the ear
- B. The presence of epistaxis
- C. A bruised periorbital area
- D. An edematous periorbital area
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.
Which data should the nurse expect to obtain during the admission assessment of a child to support the diagnosis of irritable bowel syndrome?
- A. Frequent incidents of frothy diarrhea
- B. Frequent foul-smelling ribbon stools
- C. Profuse, watery diarrhea and vomiting daily
- D. Diffuse abdominal pain unrelated to meals or activity
Correct Answer: D
Rationale: Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option 1 is a clinical manifestation of lactose intolerance. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease.
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
- A. Fetal heart rate
- B. Maternal heart rate
- C. Fetal scalp sampling
- D. Maternal blood pressure
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
- A. Pinpoint petechiae noted on both legs
- B. Whitish vesicles located across the chest
- C. Petechiae spots that are reddish and pinpoint on the soft palate
- D. Small, blue-white spots with a red base found on the buccal mucosa
Correct Answer: D
Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.