Nokea
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
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Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileus
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Renal disease impairs potassium excretion, leading to hyperkalemia, so avoiding high-potassium foods is critical. The other conditions are more associated with hypokalemia. Physiological Adaptation
For a client with Graves' disease, which nursing intervention promotes comfort?
- A. Restricting intake of oral fluids
- B. Placing extra blankets on the client's bed
- C. Limiting intake of high-carbohydrate foods
- D. Maintaining room temperature in the low-normal range
Correct Answer: D
Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
- A. obtain an order for a stool softener.
- B. administer packed RBCs, if ordered.
- C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
- D. dress venipuncture sites immediately to prevent infection.
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
- A. Pain is in the left upper quadrant of the abdomen
- B. Client reports steatorrhea for the last 3 days
- C. A serum amylase level of 366 U/L
- D. Assessed diminished bowel sounds
Correct Answer: C
Rationale: The client's amylase level is elevated above the normal level of 200 U/L. This measurement is the most accurate indicator of pancreatitis and the most objective and specific. The answers in A, B, and D are also clinical manifestations of pancreatitis, but are not as specific as the laboratory value, so they are incorrect choices.