Nokea
An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?
- A. Do you have a history of a recent brain abscess?
- B. Do you have a chronic hearing problem in the left ear?
- C. Do you successfully obtain pain relief with acetaminophen?
- D. Do you have a history of a recent upper respiratory infection (URI)?
Correct Answer: D
Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated.
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The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?
- A. Polyuria
- B. Cardiac dysrhythmias
- C. Dry mucous membranes
- D. Prolonged bleeding time
Correct Answer: B
Rationale: The inadequate production of aldosterone in clients with Addison's disease causes the inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Based on this information, none of the remaining options are manifestations that are associated with Addison's disease or hyperkalemia.
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 is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply.
- A. Temporary aphasia
- B. Throbbing headaches
- C. Transient hemiplegia
- D. Paresthesias of the hands and feet
- E. Unexplained loss of consciousness
Correct Answer: A,C,D
Rationale: Cerebral thrombosis does not occur suddenly. During the few hours or days before a thrombotic stroke, the client may experience a transient loss of speech (aphasia), hemiplegia, or paresthesias on one side of the body. Other signs and symptoms of thrombotic stroke vary, but they may include dizziness, cognitive changes, or seizures. Headache is rare, and a loss of consciousness is not likely to occur.
The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
- A. The child is unable to think clearly and rapidly.
- B. The child is unable to recognize place or person.
- C. The child always requires considerable stimulation for arousal.
- D. The child has limited interaction with the environment unless aroused.
Correct Answer: D
Rationale: If the child is obtunded, the child sleeps unless aroused and, when aroused, has limited interaction with the environment. The remaining options describe confusion, disorientation, and stupor.
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.