Nokea
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
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Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by
- A. Seeking medical help for the victim's injuries
- B. Minimizing the episode and underestimating the victim's injuries
- C. Contacting a close friend and asking for help
- D. Being very remorseful and assisting the victim with medical care
Correct Answer: B
Rationale: Minimizing the episode and underestimating the victim's injuries. Batterers often use denial to downplay the severity of their actions.
The nurse is talking with a client's spouse who insists on being present in the room while the client is receiving CPR. Which of the following actions should the nurse take?
- A. Call security to escort the spouse to the waiting room.
- B. Let the spouse stay and assign a staff member to explain the situation.
- C. Allow the spouse to stay in the room but out of sight of the resuscitation efforts.
- D. Inform the spouse that family members are not allowed in a client's room during emergency situations.
Correct Answer: B
Rationale: Allowing the spouse to stay with a staff member to explain reduces distress and supports family presence, which is often permitted during CPR.
The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman?
- A. Provide a long-term support group
- B. Help her feel like a survivor
- C. Point out the ways she behaved
- D. Be able to blame the abuser
Correct Answer: B
Rationale: Feeling like a survivor empowers the woman, fostering resilience and self-efficacy, the most important long-term goal in domestic violence recovery.
A client with seizure disorder has an order for Dilantin (Phenytoin). Which of the following is not a side effect of Dilantin (Phenytoin)?
- A. Gingival hypertrophy
- B. Insomnia
- C. Diarrhea
- D. Slurred speech
Correct Answer: B
Rationale: Dilantin causes gingival hypertrophy, slurred speech, and occasionally diarrhea, but insomnia is not a common side effect.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
- A. Prevent insensible water loss.
- B. Provide a moist environment with oxygen at 30%.
- C. Prevent dehydration and reduce fever.
- D. Liquefy secretions and relieve laryngeal spasm.
Correct Answer: D
Rationale: A cool, high-humidity tent liquefies secretions and relieves laryngeal spasm in croup, easing breathing. It does not primarily prevent water loss, deliver 30% oxygen, or reduce fever.