Nokea
The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
- A. Measuring the urinary output
- B. Checking the vital signs
- C. Encouraging increased fluid intake
- D. Weighing the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. A 3+ patellar tendon reflex
- B. Respirations of 12 breaths/min
- C. Urine output of 40 mL/hr
- D. A 2+ proteinuria value
Correct Answer: B
Rationale: MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to increase her caloric intake.
- D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
- A. Vitamin C
- B. Vitamin B1
- C. Vitamin D
- D. Vitamin A
Correct Answer: A
Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.