Nokea
A client with a temperature of 103°F (39.4°C).
Body compensatory mechanisms would include which of the following?
- A. Decreased respiratory rate and bradycardia.
- B. Normal blood pressure and pulse.
- C. Increased respiratory rate and tachycardia.
- D. Diaphoresis with cool, clammy skin.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) respirations and heart rate will increase with fever (2) blood pressure and pulse usually increase with fever (3) correct-hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate (4) diaphoresis may occur, but the skin will be warm
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When an autistic client begins to eat with her hands, the nurse can best handle the problem by
- A. Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.'
- B. Commenting, 'I believe you know better than to eat with your hand.'
- C. Jokingly stating, 'Well I guess fingers sometimes work better than spoons.'
- D. Removing the food and stating, 'You can't have anymore food until you use the spoon.'
Correct Answer: A
Rationale: Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.' This provides clear instruction and encourages adaptive behavior.
The nurse is caring for a client with a history of dementia.
- A. Which intervention is most effective for communicating with a client with dementia?
- B. Speak loudly to ensure understanding.
- C. Use simple, clear sentences.
- D. Ask open-ended questions.
- E. Provide written instructions.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.
The nurse is caring for a client with a history of cirrhosis.
- A. Which assessment finding is most concerning for a client with cirrhosis?
- B. Ascites and peripheral edema.
- C. Jaundice and pruritus.
- D. Asterixis and confusion.
- E. Dark, tarry stools.
Correct Answer: C
Rationale: Asterixis and confusion indicate hepatic encephalopathy, a life-threatening complication of cirrhosis due to ammonia buildup, requiring immediate intervention. Ascites, jaundice, and melena are concerning but less acute.
A 46-year-old man with newly diagnosed diabetes mellitus.
Which of the following responses by the nurse is BEST?
- A. It is best to buy new shoes in the morning.'
- B. Have each foot measured every time you buy new shoes.'
- C. Buy shoes one half size larger than your foot size so the fit is roomy.'
- D. Buy vinyl shoes because they won't lose their shape easily.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should buy shoes in the afternoon when feet are larger than in the morning (2) correct-feet enlarge with age, don't break in shoes all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they 'breathe', vinyl could cause foot to perspire and aggravate fungal infections
The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman. The nurse in the outpatient clinic teaches the client about the medication. The nurse should encourage the client to make sure her diet has adequate
- A. sodium.
- B. protein.
- C. potassium.
- D. iron.
Correct Answer: A
Rationale: alkali metal salt acts like sodium ions in body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity