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The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid 'vena caval syndrome,' a condition which:
- A. Occurs when blood pressure increases sharply with changes in position
- B. Results when blood flow from the extremities is blocked or slowed
- C. Is seen mainly in first pregnancies
- D. May require medication if positioning does not help
Correct Answer: B
Rationale: Vena caval syndrome occurs when the gravid uterus compresses the inferior vena cava, slowing blood return from the extremities.
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The client is prescribed alendronate (Fosamax) for osteoporosis. Which instruction should the nurse include?
- A. Take the medication with a full glass of water.'
- B. Take the medication with meals.'
- C. Lie down for 30 minutes after taking it.'
- D. Take it at bedtime.'
Correct Answer: A
Rationale: Alendronate should be taken with a full glass of water on an empty stomach, and the client should remain upright for 30 minutes to prevent esophageal irritation. Meals and lying down reduce absorption.
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Loss of ability to speak and communicate effectively
- B. Aspiration and weight loss
- C. Secondary infection resulting from poor oral hygiene
- D. Drooling
Correct Answer: B
Rationale: Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
The nurse is preparing to administer insulin to a client with type 1 diabetes. The client is to receive 10 units of NPH insulin and 5 units of regular insulin in the same syringe. Which action is correct?
- A. Draw up the regular insulin first, then the NPH insulin.
- B. Draw up the NPH insulin first, then the regular insulin.
- C. Mix the insulins in a separate vial before drawing up.
- D. Administer the insulins in two separate injections.
Correct Answer: A
Rationale: To prevent contamination, draw up regular (clear) insulin first, then NPH (cloudy). Mixing in a vial (C) is incorrect, and separate injections (D) are unnecessary.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.