Nokea
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
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A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?
- A. Nausea
- B. Heartburn
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Trimethobenzamide is an antiemetic agent that is used for the treatment of nausea and vomiting. The medication is not used to treat heartburn, constipation, or abdominal pain.
The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?
- A. Urinary output is increased.
- B. Presence of trace urinary protein
- C. Client complaints of blurred vision
- D. Blood pressure reading at prenatal baseline
Correct Answer: C
Rationale: Client complaints of headache or blurred vision indicate a worsening of the condition and warrant immediate further evaluation. The remaining options are all signs that the gestational hypertension is being resolved.
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
- A. One contraction per minute, with resultant cervical dilation
- B. Four contractions every 5 minutes, with resultant cervical dilation
- C. One contraction every 10 minutes, without resultant cervical dilation
- D. Three to 5 contractions in a 10-minute period, with resultant cervical dilation
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
An adult client with hyperkalemia is prescribed sodium polystyrene sulfonate. Which serum potassium level is a clinical indicator of effective therapy?
- A. 4.9 mEq/L (4.9 mmol/L)
- B. 5.4 mEq/L (5.4 mmol/L)
- C. 5.8 mEq/L (5.8 mmol/L)
- D. 6.2 mEq/L (6.2 mmol/L)
Correct Answer: A
Rationale: The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Option 1 is the only option that reflects a value within this range. The remaining options identify hyperkalemic levels.