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The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
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Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
- A. Initiate a referral for ophthalmic evaluation as soon as possible.
- B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve
- C. Instruct the client to rest, and report to the emergency department if eye pain develops.
- D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
- A. Assess the client's oxygen saturation level.
- B. Determine the client's current glucose level
- C. Give the client one-half cup of fruit juice.
- D. Give the client skim milk and crackers.
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.
The nurse establishes a nursing problem of 'Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis.' Which nursing intervention should the nurse include in the plan of care for this client?
- A. Assist the client with learning how to set priorities and pace activities.
- B. Instruct the client about the importance of maintaining bedrest.
- C. Consult the discharge planner about transferring the client to an assisted living center.
- D. Offer assurance that the fatigue inducing stage of the disease does not last.
Correct Answer: A
Rationale: Pacing activities balances exertion and rest, reducing fatigue in rheumatoid arthritis, unlike bedrest, relocation, or reassurance.
A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.