Nokea
The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.
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A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.
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.
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step to ensure early treatment if positive.
The nurse is to perform a routine blood glucose check on a diabetic client before administering insulin. Which action is correct?
- A. Puncture the end of the thumb in the middle of the fleshy part.
- B. Puncture the end of the finger on the side.
- C. Draw blood from the antecubital vein in the arm.
- D. Puncture the finger and collect the blood in a vial.
Correct Answer: B
Rationale: Puncturing the finger's side avoids nerve-rich areas, ensuring accurate and less painful glucose testing.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
- A. Impaired adjustment
- B. Impaired home maintenance
- C. Ineffective family therapeutic regimen management
- D. Noncompliance
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.