Nokea
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
- A. The client's knowledge of the signs of preterm labor
- B. The client's feelings about the pregnancy
- C. Whether the client was using a method of birth control
- D. The client's thought about future children
Correct Answer: B
Rationale: Assessing the client's feelings about the pregnancy is critical at 10 weeks to tailor education and support to her emotional needs.
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The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
- A. Risk for ineffective breathing pattern
- B. Risk for imbalanced body temperature
- C. Risk for decreased cerebral tissue perfusion
- D. Activity intolerance
Correct Answer: B
Rationale: Thyroid crisis (thyroid storm) causes hyperthermia, making imbalanced body temperature the priority due to the risk of life-threatening hypermetabolic complications.
A child with thrush has been prescribed fluconazole (Diflucan). The child's mother asks what this medication is used for, and the nurse correctly replies,
- A. This is an antiviral medication used to treat your child's viral infection.'
- B. This medication is used to treat yeast infections.'
- C. This medication is an analgesic that will ease your child's pain while eating.'
- D. This is an antibiotic for your child's bacterial infection.'
Correct Answer: B
Rationale: Fluconazole is an antifungal used to treat thrush, a yeast infection caused by Candida.
The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
- A. I will not let him use a straw.
- B. I will turn on the television during meals.
- C. Instead of whole pills, I will crush the pill and place it in custard.
- D. He will sit up for a half hour after eating.
Correct Answer: B
Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
- A. Pupillary changes
- B. Projectile vomiting
- C. Wheezing respirations
- D. Sudden, intense pain
Correct Answer: A
Rationale: After administering naloxone, the nurse should assess for pupillary changes, as reversal of opioid effects can cause sympathetic stimulation, affecting pupil size.
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
- A. The client can have a higher-calorie diet.
- B. The client has good control of her diabetes.
- C. The client requires adjustment in her insulin dose.
- D. The client has poor control of her diabetes.
Correct Answer: B
Rationale: A glycosylated hemoglobin (HbA1c) of 2.5% is below the normal range (4-5.6%), indicating overly tight glucose control, but in context, it suggests good diabetes management.