Nokea
The nurse is caring for a child diagnosed with Reye's syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?
- A. Protein in the urine
- B. Symptoms of hyperglycemia
- C. Increased intracranial pressure
- D. A history of a staphylococcus infection
Correct Answer: C
Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. Intracranial pressure and encephalopathy are major problems associated with Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
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A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse should be most alert to signs of hypoglycemia at what time during the day?
- A. 9:30 am to 11:30 am
- B. 11:30 am to 1:30 pm
- C. 1:30 pm to 3:30 pm
- D. 3:30 pm to 5:30 pm
Correct Answer: A
Rationale: Regular insulin is a short-acting insulin. Its onset of action occurs in a half hour and peaks in 2 to 4 hours. Its duration of action is 4 to 6 hours. A hypoglycemic reaction will most likely occur at peak time, which in this situation is between 9:30 am and 11:30 am.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply.
- A. Hunger
- B. Sweating
- C. Weakness
- D. Nervousness
- E. Cool clammy skin
- F. Increased urinary output
Correct Answer: A,B,C,D,E
Rationale: Hypoglycemia is characterized by a blood glucose level less than 70 mg/dL (4 mmol/L). Clinical manifestations of hypoglycemia include hunger, sweating, weakness, nervousness, cool clammy skin, blurred vision or double vision, tachycardia, and palpitations. Increased urinary output is a manifestation of hyperglycemia.
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
- A. Monitoring for heel breakdown
- B. Monitoring for bladder distention
- C. Monitoring for extremity shortening
- D. Monitoring for blanching ability of toe nail beds
Correct Answer: D
Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.
An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure?
- A. Try to swallow.
- B. Hold your breath.
- C. Breathe normally.
- D. Roll the tongue to the back of the mouth.
Correct Answer: C
Rationale: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.