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An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?
- A. Had a cold and ear infection for the past two days
- B. Missed a dose of insulin
- C. Did not follow dietary restrictions
- D. Overexerted during exercise
Correct Answer: A
Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.
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A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
- A. Encourage the client to eat large meals in one sitting.
- B. Offer the client frequent snacks of foods he enjoys.
- C. Provide the client with foods high in fiber to improve digestion.
- D. Discourage eating late at night to prevent weight gain.
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?
- A. Increase fluid intake to prevent crystalluria.
- B. Take the medication with meals to prevent GI upset.
- C. Avoid sunlight exposure while taking the medication.
- D. Report any changes in the color of urine.
Correct Answer: A
Rationale: The correct answer is to increase fluid intake to prevent crystalluria, a potential side effect of ciprofloxacin. Crystalluria is the formation of crystals in the urine, which can be reduced by maintaining adequate hydration. Choice B is incorrect because ciprofloxacin can be taken with or without food. Choice C is incorrect as avoiding sunlight exposure is more relevant for medications that cause photosensitivity, not typically a concern with ciprofloxacin. Choice D is less essential than choice A because while reporting changes in urine color is important, preventing crystalluria through adequate fluid intake is a higher priority.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?
- A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
- B. A client with a myocardial infarction that is free from pain and dysrhythmias
- C. A client with a tracheotomy of 24 hours in some respiratory distress
- D. A client with a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.
The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?
- A. A 17-year-old client with schizophrenia who is pacing the hallways
- B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
- C. A 16-year-old client with depression who refuses to eat meals
- D. A 15-year-old client with anxiety who is quietly reading in a corner
Correct Answer: B
Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?
- A. Trendelenburg
- B. Supine
- C. Prone
- D. Fowler's
Correct Answer: D
Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.