Nokea
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
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A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become
- A. darker and more pigmented.
- B. ruddy and oily.
- C. puffy and scaly.
- D. pale and dry.
Correct Answer: A
Rationale: increase in melanocyte-stimulating hormone results in 'eternal tan'
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
The physician orders naproxen sodium (Anaprox) 250 mg enteric-coated tablets PO bid for a 45-year-old man.
Which response, if made by the client, would indicate that the nurse's teaching about the medication has been effective?
- A. I can join my wife in a glass of wine with our dinner when we eat in a restaurant.'
- B. I should avoid milk and dairy products when I take this pill.'
- C. I should call my doctor if my stools turn very dark.'
- D. I don't like to take pills so I will crush the pill and add it to some applesauce.'
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a true statement. (1) alcohol increases risk of GI bleeding (2) should be taken with food, milk, or antacid to decrease GI upset (3) correct-NSAIDS can cause GI bleeding (4) enteric-coated tablet should not be broken
A client is scheduled for electromyography (EMG).
What should the nurse tell the client about the procedure?
- A. Your hair will be carefully washed prior to the procedure.'
- B. This is a noninvasive procedure that takes about 30 minutes.'
- C. A sedative will be given to you shortly before the procedure.'
- D. You will not be allowed to eat 4-6 hours before the procedure.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) usually performed on the legs (2) correct-electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair Test results (4) doesn't involve general anesthesia or GI system
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I should change the pouch when it’s about one-third full.
- B. I should empty the pouch every morning.
- C. I should eat a high-fiber diet to prevent constipation.
- D. I should check the skin around the stoma for irritation.
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.