Nokea
The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
- A. intimacy versus isolation
- B. ego integrity versus despair
- C. identity versus role confusion
- D. generativity versus stagnation
Correct Answer: B
Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.
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The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?
- A. If he is vomiting, I shouldn't give him any insulin.
- B. I should bring him to the doctor if he develops a fever.
- C. If our grandchildren are sick, they probably shouldn't come to visit.
- D. I should call the doctor if he has nausea or abdominal pain lasting for more than 1 or 2 days.
Correct Answer: A
Rationale: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.
The nurse is caring for a client with morning sickness who is 8 weeks pregnant with her first child. What should the nurse advise the client to do to manage nausea?
- A. eat an omelet for breakfast to ensure adequate protein intake
- B. eat foods served warm with moderate amounts of spices
- C. consume most of the daily fluid intake early in the day
- D. brush the teeth immediately after eating; this helps get the food taste out that may trigger nausea
Correct Answer: C
Rationale: Consuming fluids early avoids triggering nausea later. Protein-heavy meals, spicy foods, or brushing teeth post-eating may worsen nausea.
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
- A. Location 1
- B. Location 2
- C. Location 3
- D. Location 4
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
- A. Nothing to be concerned about
- B. Signs/symptoms of acute glomerulonephritis
- C. Signs/symptoms of the normal progression of scarlet fever
- D. Symptoms of an allergic reaction to penicillin G potassium
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.