Nokea
The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client?
- A. Tell the client to avoid stairs
- B. Tell the client to decrease her intake of sodium
- C. Instruct the client to weigh daily
- D. Tell the client to report numbness and tingling in her feet and toes
Correct Answer: D
Rationale: Numbness and tingling in the feet and toes may indicate diabetic neuropathy a serious complication requiring prompt reporting. Avoiding stairs reducing sodium or daily weighing are not specific to diabetes management unless indicated.
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Which of the following lab data is representative of a client with aplastic anemia?
- A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
- B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
- C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
- D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
Correct Answer: D
Rationale: (A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Obtain an accurate weight
- B. Search the client's purse for pills
- C. Assess vital signs
- D. Assign her to a room with someone her own age
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
An elderly client has been noted to have increasing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing:
- A. Proprioception
- B. Agnosia
- C. Sundowning
- D. Confabulation
Correct Answer: C
Rationale: Sundowning is increased confusion or agitation in the late afternoon or evening common in elderly patients with dementia. Proprioception agnosia and confabulation do not describe this time-specific behavior.
A client has recently been diagnosed with primary open-angle glaucoma. The nurse should tell the client to avoid taking:
- A. Aleve (naprosyn)
- B. Benadryl (diphenhydramine)
- C. Tylenol (acetaminophen)
- D. Robitussin (guaifenesin)
Correct Answer: B
Rationale: Benadryl, an antihistamine, can increase intraocular pressure, worsening primary open-angle glaucoma, so it should be avoided.
The nurse is evaluating the client's pulmonary artery pressure (PAP). The nurse is aware that PAP evaluates:
- A. Pressure in the left ventricle
- B. Systolic, diastolic, and mean pressure in the pulmonary artery
- C. Pressure in the pulmonary veins
- D. Pressure in the right ventricle
Correct Answer: B
Rationale: Pulmonary artery pressure (PAP), measured via a pulmonary artery catheter, reflects systolic, diastolic, and mean pressures in the pulmonary artery, indicating right ventricular function and pulmonary circulation status.