Nokea
The nurse is caring for a client with a history of diabetes insipidus.
- A. Which symptom is expected in a client with diabetes insipidus?
- B. Weight gain and edema.
- C. Polyuria and thirst.
- D. Hypotension and bradycardia.
- E. Hyperglycemia and fatigue.
Correct Answer: B
Rationale: Polyuria and thirst result from diabetes insipidus due to insufficient antidiuretic hormone, leading to excessive water loss. Weight gain, edema, hypotension, and hyperglycemia are unrelated.
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The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin glargine (Lantus). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should not mix this insulin with other insulins.
- C. I should rotate injection sites.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin glargine when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, it should not be mixed, and rotation prevents lipodystrophy.
Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance imaging?
- A. The client is an insulin-dependent diabetic.
- B. The client refuses a corner bed.
- C. The client is allergic to shellfish.
- D. The client has a history of asthma.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for MRI contrast dye, requiring further assessment. Diabetes , bed preference , and asthma are not contraindications.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM.
- A. What is the most appropriate action for a saturated dressing with dark, greenish-yellow drainage two hours after T-tube removal?
- B. Remove the dressing and replace it with a more absorbent dressing.
- C. Collect a culture and sensitivity specimen of the drainage.
- D. Observe the wound for dehiscence.
- E. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile after T-tube removal. Replacing the saturated dressing with a more absorbent one keeps the site clean and dry, preventing infection. Cultures are unnecessary without infection signs, dehiscence is unlikely, and reinforcing risks infection.
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do