Nokea
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.
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Which statement made by an adolescent indicates understanding of how to reduce risk of osteoporosis later in life?
- A. I will be careful not to sprain my ankle when I play sports.'
- B. I drink a glass of milk with every meal.'
- C. As I get older, I will reduce the amount of weight-bearing exercise I do.'
- D. My favorite beverages are cola drinks.'
Correct Answer: B
Rationale: High calcium intake (milk) builds bone density, reducing osteoporosis risk. Sprains, reduced exercise, or cola drinks don't address bone health.
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following instructions should the nurse include?
- A. Take the medication with milk.
- B. Remain upright for 30 minutes after taking.
- C. Stop the medication if bone density improves.
- D. Avoid regular bone density Test s.
Correct Answer: B
Rationale: Remaining upright for 30 minutes prevents esophageal irritation from alendronate. Options A, C, and D are incorrect.
A 4 lb 10 oz baby boy delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has mottling of the skin and acrocyanosis with irregular respirations of 60.
The nurse should recognize these findings as signs of
- A. hypoglycemia.
- B. cold stress.
- C. birth asphyxia.
- D. hypovolemia.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) blood sugar less than 25 mg/dL, would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct-symptoms describe cold stress (3) would see meconium stained amniotic fluid (4) would see symptoms of shock
A 5-year-old child has been treated for sickle cell crisis. The parent asks the nurse if there is anything that can be done to prevent future crises. What should be included in the nurse's response?
- A. Sickle crisis is hard to predict and not usually preventable.
- B. Keeping the child from getting chilled may prevent a crisis.
- C. Fevers, vomiting, and diarrhea should be reported to the physician immediately.
- D. Giving the child aspirin on a daily basis lessens the frequency of crises.
Correct Answer: C
Rationale: Fevers, vomiting, and diarrhea can trigger sickle cell crisis by causing dehydration or infection, so prompt reporting allows early intervention to prevent crises.
The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.