Nokea
An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
- A. 2 to 5 of a simple carbohydrate.
- B. 18 to 20 g of a simple carbohydrat
- C. 10 to 15 g of a simple carbohydrate.
- D. 25 to 30 g of a simple carbohydrate.
Correct Answer: C
Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.
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A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
- A. Patient will have one soft, formed bowel movement by end of shift.
- B. Patient will walk unassisted to bathroom by the end of shift.
- C. Patient will be offered laxatives or stool softeners this shift.
- D. Patient will not take any pain medications this shift.
Correct Answer: A
Rationale: The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan.
Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity.
A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures.
B: Use of tilt board may not directly address the need for proper positioning to prevent contractures.
C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: B
Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges.
A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior.
C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation.
D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
- A. You should wear gloves when handling his linen and bedding
- B. You should keep the windows and doors closed so as not to spread the droplets
- C. He must be careful to cough into a handkerchief that is washed in hot water or discarded
- D. Make sure to boil all water before drinking or using it
Correct Answer: C
Rationale: Rationale:
Step 1: Coughing is the primary way TB bacteria are spread.
Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained.
Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading.
Step 4: This method reduces the risk of infecting family members.
Summary of Incorrect Choices:
A: Wearing gloves does not prevent airborne transmission of TB.
B: Keeping windows closed can increase the concentration of bacteria in the air.
D: Boiling water is not necessary to prevent TB transmission.