Nokea
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.
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Which of the following assessments is the most important for a patient receiving IV potassium?
- A. Respiratory rate
- B. Heart rate
- C. Blood pressure
- D. Oxygen saturation
Correct Answer: C
Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.
After a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, assessing the client for a cerebrospinal fluid (CSF) leak is crucial due to the risk of this serious complication. A CSF leak can lead to infection and increased intracranial pressure, which must be promptly identified and managed to prevent further complications. Fluctuating blood glucose levels (Choice B) are not directly associated with a transsphenoidal hypophysectomy. Cushing's syndrome (Choice C) is a condition related to prolonged exposure to high levels of cortisol and is not a common immediate concern post-transsphenoidal hypophysectomy. Cardiac arrhythmias (Choice D) are not typically a direct complication of this surgical procedure, making it a less relevant concern compared to a CSF leak.
The client with chronic renal failure is being taught about dietary restrictions by the nurse. Which of the following food items should the client avoid?
- A. Apples
- B. Bananas
- C. Chicken
- D. Rice
Correct Answer: B
Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which should be limited in clients with chronic renal failure to prevent hyperkalemia. Apples (choice A), chicken (choice C), and rice (choice D) are not typically restricted in clients with chronic renal failure. Apples and rice are lower in potassium, while chicken is a good source of lean protein, which is usually encouraged in these clients to meet their protein needs without excess potassium intake.
If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:
- A. Explaining how the risk factor behaviors lead to poor health.
- B. Withholding praise until the new behavior is well established.
- C. Rewarding the client whenever the acceptable behavior is performed.
- D. Instilling mild fear in the client to extinguish the behavior.
Correct Answer: C
Rationale: The correct answer is C. A fundamental principle of behavior modification is that behavior that is rewarded is more likely to be continued. Therefore, rewarding the client whenever the acceptable behavior is performed is the best approach to reinforce new adaptive behaviors. Choice A is incorrect because simply explaining how the risk factor behaviors lead to poor health may not be as effective in promoting behavior change compared to positive reinforcement. Choice B is incorrect because withholding praise can hinder progress and motivation for the client. Choice D is incorrect because instilling fear is not a recommended method in behavior modification. It can lead to negative psychological effects and is not a sustainable approach to behavior change.
After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?
- A. Hyperkalemia.
- B. Hypotension.
- C. Infection.
- D. Fever.
Correct Answer: B
Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.