Nokea
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
An INITIAL nursing priority is to
- A. provide adequate hygiene and nutrition.
- B. decrease environmental stimuli.
- C. slowly involve the client in unit activities.
- D. administer and monitor sedative and mood-stabilizing medications.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
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The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin glargine (Lantus). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should not mix this insulin with other insulins.
- C. I should rotate injection sites.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin glargine when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, it should not be mixed, and rotation prevents lipodystrophy.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
- A. Impaired adjustment
- B. Impaired home maintenance
- C. Ineffective family therapeutic regimen management
- D. Noncompliance
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
An arthritic client must be able to perform tasks to manage at home alone following discharge from the hospital.
The nurse knows that to manage at home alone following discharge from the hospital, an arthritic client must be able to perform which of the following tasks?
- A. Climb up and down stairs.
- B. Lace and tie his/her shoes.
- C. Comb his/her hair and brush his/her teeth.
- D. Walk without assistance.
Correct Answer: C
Rationale: Strategy: Think about the significance of each answer choice and how it relates to arthritis. (1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct-is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid drinking alcohol while taking this medication.
- B. I should take this medication with food.
- C. I should report any bruising to my doctor.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping methotrexate when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: alcohol increases hepatotoxicity, food reduces GI upset, and bruising may indicate thrombocytopenia.
A woman has been recently diagnosed with systemic lupus and shares with the nurse, 'I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy since I have lupus.'
- A. What is the best response by the nurse to a woman with systemic lupus considering pregnancy?
- B. Most women find that they feel better when they are pregnant.'
- C. How long have you been in remission?'
- D. Women with lupus frequently have slightly longer gestations.'
- E. It is best to become pregnant within the first six months of diagnosis.'
Correct Answer: B
Rationale: The nurse should assess the duration of remission, as women with systemic lupus erythematosus (SLE) should be in remission for at least 5 months before conceiving to minimize risks of maternal and fetal complications. Pregnancy does not typically improve SLE symptoms, gestation length is unaffected, and early pregnancy post-diagnosis is not recommended.