Nokea
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
- A. My child has lost 3 pounds in the last month.
- B. Urinary output seemed to be less over the past 2 days.
- C. All the pants have become tight around the waist.
- D. The child prefers some salty foods more than others.
Correct Answer: C
Rationale: All the pants have become tight around the waist. Increased abdominal girth is an early sign of Wilm's tumor.
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Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
- A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessment, which should occur in longer than 3-month intervals
- B. A glycosylated hemoglobin is to be obtained at least two years
- C. A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
- D. A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Correct Answer: A
Rationale: The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care for clients with poor glycemic control.
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)
The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
- A. client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1-10
- B. client who had an open reduction of the right femur and is reporting nausea
- C. client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
- D. client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.
The nurse is contributing to the plan of care for an 8-year-old client with autism spectrum disorder. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Establish a consistent schedule for providing care.
- B. Encourage the parents to be present when providing care.
- C. Assign the same staff members to care for the client when possible.
- D. Place the client in a private room with familiar belongings.
- E. Use therapeutic touch to comfort the client.
Correct Answer: A,B,C,D
Rationale: Consistency in schedule (A), parental presence (B), familiar staff (C), and a private room with familiar items (D) reduce anxiety in children with autism. Therapeutic touch (E) may be distressing due to sensory sensitivities.