Nokea
The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?
- A. The mother who took her children from school because aliens were after them.
- B. The young man who has a history of substance abuse and no telephone.
- C. The newly diagnosed client who needs to be evaluated for medication compliance.
- D. The young woman who believes she is to blame for her recent miscarriage.
Correct Answer: A
Rationale: The correct answer is A: The mother who took her children from school because aliens were after them should be seen first. This choice indicates potential harm to the children due to the mother's delusions, posing an immediate safety concern. The nurse needs to assess the situation and ensure the children's safety. Choices B, C, and D do not present immediate safety risks. B is a history of substance abuse but no current immediate danger. C is newly diagnosed and can wait for evaluation, as can D who may need support but is not in immediate danger. Prioritizing safety is crucial in mental health nursing.
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In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?
- A. Serum creatinine
- B. White blood cell count
- C. Hemoglobin level
- D. Serum potassium
Correct Answer: C
Rationale: Rationale: The correct answer is C, hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in CKD patients with anemia. Monitoring hemoglobin levels helps assess the effectiveness of the therapy in improving anemia. If hemoglobin levels increase, it indicates the therapy is working.
Summary of incorrect choices:
A: Serum creatinine - This measures kidney function, not the effectiveness of erythropoietin therapy for anemia in CKD patients.
B: White blood cell count - Monitors immune function, not related to erythropoietin therapy for anemia.
D: Serum potassium - Important for monitoring electrolyte balance in CKD patients but not specific to assessing erythropoietin therapy effectiveness.
A client with a new diagnosis of diabetes mellitus is learning to self-administer insulin. Which instruction should the nurse include?
- A. Store the insulin in the freezer.
- B. Administer the insulin at the same site each time.
- C. Rotate injection sites within the same region.
- D. Shake the vial vigorously before drawing up the insulin.
Correct Answer: C
Rationale: The correct answer is C: Rotate injection sites within the same region. This is important to prevent lipohypertrophy and ensure proper insulin absorption. Administering insulin at the same site each time (B) can lead to tissue damage. Storing insulin in the freezer (A) can alter its effectiveness. Shaking the vial vigorously (D) can cause air bubbles and affect insulin dosage accuracy. Rotation of injection sites within the same region is crucial for consistent absorption and preventing complications.
A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?
- A. Administer regular insulin intravenously.
- B. Give oral hypoglycemic agents.
- C. Administer sodium bicarbonate.
- D. Provide a high-calorie diet.
Correct Answer: A
Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.
Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a medical emergency that can lead to tissue damage and loss of limb function. Immediate intervention is crucial to prevent further complications. Finger paresthesias related to carpal tunnel syndrome (A) are not life-threatening and can be managed conservatively. Morton's neuroma (C) and plantar fasciitis (D) are painful conditions, but they do not pose an immediate threat to the client's health or limb function.
A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?
- A. Have the patient void immediately before the procedure.
- B. Position the patient flat in bed.
- C. Administer a full liquid diet.
- D. Encourage the patient to ambulate for 30 minutes.
Correct Answer: A
Rationale: The correct answer is A: Have the patient void immediately before the procedure. This step is crucial to prevent accidental puncture of the bladder during paracentesis. Voiding helps empty the bladder, reducing the risk of injury and ensuring a safer procedure.
Incorrect choices:
B: Position the patient flat in bed - Incorrect, as the patient should be in a sitting position with legs dangling over the side of the bed during the procedure.
C: Administer a full liquid diet - Incorrect, as a full liquid diet is not necessary for paracentesis preparation.
D: Encourage the patient to ambulate for 30 minutes - Incorrect, as ambulation is not relevant to preparing for paracentesis.