Nokea
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
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The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
A client suspected of having Alzheimer's disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation, the examiner names three objects. Later in the evaluation, he asks the client to name the same three objects. The examiner is testing the client's:
- A. Attention
- B. Orientation
- C. Recall
- D. Registration
Correct Answer: C
Rationale: Recalling three objects tests short-term memory (recall), a key component assessed in the Mini-Mental State Examination for Alzheimer's.
Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:
- A. The client with ulcerative colitis
- B. The client with neutropenia
- C. The client with cholecystitis
- D. The client with polycythemia vera
Correct Answer: B
Rationale: Neutropenia increases infection risk, so a private room minimizes exposure to pathogens.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply.
- A. music
- B. therapeutic massage
- C. stretching exercises
- D. relaxation
Correct Answer: A, B, C, D
Rationale: Music, therapeutic massage, stretching exercises, and relaxation are all evidence-based nonpharmacological methods to manage chronic pain.