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The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Administration of oxygen at 2 L/min
- C. Needle decompression
- D. Bronchodilator therapy
Correct Answer: C
Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.
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Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:
- A. Transport of glucose into body cells and storage of glycogen in the liver
- B. Glycogenolysis and facilitation of glucose use for energy
- C. Glycogenolysis and catabolism
- D. Catabolism and hyperglycemia
Correct Answer: A
Rationale: Lack of insulin causes glycogenolysis, catabolism, and hyperglycemia. Insulin promotes the conversion of glucose to glycogen for storage and regulates the rate at which carbohydrates are used by cells for energy. Insulin is anabolic in nature. Glucose stimulates protein synthesis within the tissue and inhibits the breakdown of protein into amino acids.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
- A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
- B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
- C. The client will be more compliant with a medication that allows some feelings of hypomania.
- D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg.
- B. Cover the bone area with a sterile dressing.
- C. Apply an ACE bandage around the entire lower limb.
- D. Place the client in the prone position.
Correct Answer: B
Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (A) is secondary, an ACE bandage (C) may contaminate the wound, and prone positioning (D) is inappropriate.
A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
- A. Hemoglobin 17.2 g/dL
- B. Platelets 250,000/mm3
- C. Serum glucose 30 mg/dL
- D. White blood cells 18,000/mm3
Correct Answer: C
Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.