Nokea
An eight-month-old infant.
The nurse should look for which of the following in assessing pain in an eight-month-old infant?
- A. Decreased pulse rate.
- B. Increased fluid intake.
- C. Decreased respiratory rate.
- D. Rubbing a body part and crying.
Correct Answer: D
Rationale: Strategy: Think about each assessment. (1) pulse rate would increase (2) nonspecific regarding pain (3) does not reflect pain (4) correct-since an infant cannot talk, nurse needs to be aware of nonverbal signs of pain, such as rubbing the ear because of an earache
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The mother of a 10-year-old boy with IDDM (insulin-dependent diabetes mellitus) calls to discuss the child’s self-monitoring blood glucose (SMBG) home readings. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood sugar readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to
- A. continue with his medication regime.
- B. check his blood sugar during the night.
- C. give his NPH insulin later in the evening.
- D. serve his bedtime snack earlier in the evening.
Correct Answer: B
Rationale: High morning blood sugars suggest rebound hyperglycemia (Somogyi effect) from nocturnal hypoglycemia, requiring nighttime glucose checks. Options A, C, and D are premature: continuing the regimen ignores the issue, and adjusting insulin or snack timing requires confirmation.
The nurse notes that the client has a pulse deficit. What is the most appropriate action for the nurse?
- A. Document this as a normal finding.
- B. Instruct the client to report to the clinic for a weekly reevaluation.
- C. Report this finding immediately to the client's physician.
- D. Teach the client how to monitor pulse at home.
Correct Answer: C
Rationale: A pulse deficit indicates irregular heartbeats, requiring immediate physician notification to assess for arrhythmias.
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.
The nurse is caring for clients in the outpatient clinic. A young adult female is seeking help for weight loss. Her weight is 257 pounds, and she is 5'7'' tall.
Which of the following indicates the MOST appropriate diet choices for breakfast?
- A. Applesauce, cream of wheat, toast.
- B. Scrambled eggs and toast, one slice of bacon.
- C. One glass of grapefruit juice.
- D. Bagel with two ounces of cream cheese and a banana.
Correct Answer: A
Rationale: Strategy: Determine the topic of the question. (1) correct-breakfast with some substance won't leave her feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content
A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase