Nokea
The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse would observe which of the following symptoms?
- A. Decerebrate posturing, BP 160/100, pulse 56.
- B. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
- C. Glucosuria, osmotic diuresis, loss of water and electrolytes.
- D. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.
Correct Answer: B
Rationale: signs of dehydration, increased output, low specific gravity, normal 1.010-1.030
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A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
- A. Bradycardia
- B. Lethargy
- C. Irritability
- D. Vomiting
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
- A. Compulsive behavior
- B. Sense of impending doom
- C. Fear of flying
- D. Predictable episodes
Correct Answer: B
Rationale: Sense of impending doom. The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: Nurses are more satisfied when opportunities exist for autonomy and control. Self-scheduling improves team morale by giving staff more control over their work schedules.
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
- A. You think that someone wants to poison you?
- B. Why do you think the food is poisoned?
- C. These feelings are a symptom of your illness.
- D. You're safe here. I won't let anyone poison you.
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.