Nokea
The client with acute hypocalcemia is admitted to the unit. Nursing action should include:
- A. Implement seizure precautions
- B. Assess for hypoglycemia
- C. Monitor for visual changes
- D. Observe for muscle weakness
Correct Answer: A
Rationale: The correct action for a client with acute hypocalcemia is to implement seizure precautions. Hypocalcemia can lead to tetany and seizures due to neuromuscular irritability. Assessing for hypoglycemia (choice B) is not directly related to hypocalcemia. Monitoring for visual changes (choice C) is more indicative of conditions like hyperglycemia or retinal disorders. Observing for muscle weakness (choice D) is a common symptom of hypocalcemia but does not address the immediate risk of seizures, which is why implementing seizure precautions is the priority nursing action.
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The nurse is teaching a community group about risks of cardiovascular disease. Several clients ask the nurse to determine their risk. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. A male with a serum cholesterol level of 199 mg/dl.
- B. A female with a serum cholesterol level of 201 mg/dl.
- C. A male with a low-density lipoprotein (LDL) level of 200 mg/dl.
- D. A female with a low-density lipoprotein (LDL) level of 160 mg/dl.
Correct Answer: C
Rationale: The correct answer is C. A male with a high LDL level (200 mg/dl) has a significant risk for cardiovascular disease. High levels of LDL cholesterol are associated with an increased risk of atherosclerosis and heart disease. Choices A, B, and D have serum cholesterol levels that are slightly elevated but are not as specific or directly linked to cardiovascular risk as high LDL levels. Therefore, the client with the high LDL level is at the greatest risk for cardiovascular disease.
The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
- A. Infant will experience minimal pain
- B. Muscle spasms will be relieved
- C. Mobility will be managed as tolerated
- D. Tissue perfusion will be maintained
Correct Answer: D
Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?
- A. "I don't remember anything about what happened to me."
- B. "I'd rather not talk about it right now."
- C. "It's all the other guy's fault! He was going too fast."
- D. "My mother is heartbroken about this."
Correct Answer: B
Rationale: The correct answer is B because the statement "I'd rather not talk about it right now" indicates that the client is consciously choosing to avoid discussing the distressing issue, which aligns with the mechanism of suppression. Choice A does not involve active avoidance but rather memory loss, which is not suppression. Choice C involves blaming others, which is a defense mechanism known as projection. Choice D involves expressing emotions rather than avoiding them, which does not align with suppression.
Which ethnic group has the highest risk for diabetes?
- A. African Americans
- B. Hispanic Americans
- C. Asian Americans
- D. Native Americans
Correct Answer: D
Rationale: Native Americans have the highest risk for diabetes compared to other ethnic groups. This is due to genetic predisposition, lifestyle factors, and limited access to healthcare. African Americans, Hispanic Americans, and Asian Americans also have an increased risk of developing diabetes, but statistically, Native Americans have the highest prevalence of the disease. Therefore, choices A, B, and C are incorrect.
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
- A. An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
- B. An adolescent admitted the prior night with Tylenol intoxication
- C. A middle-aged client with an internal automatic defibrillator and complaints of 'passing out at unknown times' admitted yesterday
- D. A school-age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts
Correct Answer: A
Rationale: The correct answer is A because a client with diabetic ketoacidosis (DKA) that is being well-managed and has shown improvement within 24 hours is more stable and can be considered for discharge sooner than those with more acute or unstable conditions. Choice B is incorrect as Tylenol intoxication may require further monitoring and intervention. Choice C is incorrect as a client with an automatic defibrillator and episodes of passing out needs careful evaluation and monitoring. Choice D is incorrect as suspected bacterial meningitis is a serious condition that typically requires a longer hospital stay for treatment and observation.