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The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
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A psychiatric nurse is assigned to conduct an admission nursing history on a new client.
- A. What should the admission nursing history for a new psychiatric client include?
- B. The nurse’s opinion regarding the mental and emotional status of the client.
- C. Data addressing the client’s emotional state.
- D. Data that address a biopsychosocial approach, including a family system assessment.
- E. Specific data detailing the client’s mental status.
Correct Answer: C
Rationale: A comprehensive psychiatric nursing history should use a biopsychosocial approach, including physical, psychological, social, and family system assessments, to provide a holistic understanding of the client’s needs. Focusing only on emotional state or mental status is too narrow, and the nurse’s opinion lacks objectivity without assessment data.
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Which of the following client statements indicates to the nurse that teaching has been successful?
- A. I need to call my doctor in a few weeks for a follow-up appointment.'
- B. I need to keep my doctor's appointment next week for a blood Test .'
- C. I can take over-the-counter sedatives if I have trouble sleeping.'
- D. I can drink alcohol as long as I drink in moderation.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
- A. Encourage the client to drink 2 L of fluid daily.
- B. Administer antipyretics as ordered.
- C. Administer antibiotics as ordered.
- D. Administer mucolytics as ordered.
- E. Ambulate three times a day.
- F. Eat three large meals a day.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
The nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa