Nokea
The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?
- A. Vital signs
- B. Motor function
- C. Sensory function
- D. Level of consciousness
Correct Answer: D
Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.
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The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
- A. Imbalanced nutrition: Less than body requirements.
- B. Acute pain related to abdominal muscle spasms.
- C. Adult failure to thrive.
- D. Ineffective health maintenance.
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
Which of the following examples should the nurse use to describe bulimia to a group of parents at a local community center?
- A. An adolescent male who uses calorie-counting to maintain his weight in the desirable range for his height.
- B. A college-age male who uses regular exercise to be able to eat and drink what he wants without gaining weight.
- C. A middle-aged female who uses diet pills occasionally to help her lose 10 lb.
- D. A college-age female who binges and then purges to prevent weight gain.
Correct Answer: D
Rationale: Bulimia is characterized by binge eating followed by purging to prevent weight gain.
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
A client takes isosorbide dinitrate (Isordil) as an antianginal medication. Which of the following statements indicates that the client understands the adverse effects of the drug?
- A. I should take my pulse before taking the medication.'
- B. I should take Isordil with food.'
- C. I will need to change positions slowly so I won't get dizzy.'
- D. It is important that I report any swelling in my ankles.'
Correct Answer: C
Rationale: Isosorbide dinitrate can cause orthostatic hypotension, so changing positions slowly prevents dizziness, indicating client understanding of adverse effects.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.