Nokea
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.
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The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?
- A. Blood pressure of 136/88 mm Hg
- B. Flat affect and drowsiness
- C. Nausea and poor appetite
- D. Respiratory rate of 12/min
Correct Answer: B
Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.