Nokea
The nurse is preparing to administer a dose of regular insulin 8 units subcutaneously. The medication is available in 100 units/mL. How many milliliters should the nurse administer?
Correct Answer: 0.08
Rationale: To calculate: 8 units desired ÷ 100 units/mL = 0.08 mL. The nurse should administer 0.08 mL of regular insulin.
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A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Books with colorful pictures
- B. Music
- C. Riding toys
- D. Puppets
Correct Answer: D
Rationale: Puppets allow expression of feelings and fears that otherwise could not be directly communicated, helping the child articulate emotions.
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Small, frequent feedings of foods that can be carried
- B. Tube feedings with nutritional supplements
- C. Allowing him to eat when and what he wants
- D. Giving him a quiet place where he can sit down to eat meals
Correct Answer: A
Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
- A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.
- B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
- C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
- D. Respect the client's family's wishes.
Correct Answer: D
Rationale: It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. The nurse should leave the room and allow the family privacy in their grief. The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.