Nokea
A 24-year-old woman who is 30 weeks pregnant is seen in the outpatient clinic for a routine visit.
The nurse would be MOST concerned if the client made which of the following statements?
- A. During the day I seem to get hot flashes and chills.
- B. I am having some trouble with constipation and hemorrhoids.
- C. At the end of the day I have leg cramps.
- D. When I put my hand on my abdomen, I can feel it tense and relax.
Correct Answer: A
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) correct-should be reported to the physician (2) common due to pressure of growing fetus (3) common due to compression of nerves supplying lower extremities or reduced calcium levels, should take oral calcium supplements if ordered, stretch until spasm is relieved (4) Braxton-Hicks contractions common, should rest and change position
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A patient with type I diabetes mellitus (IDDM) asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?
- A. Human insulin is less likely to cause you to have a localized allergic reaction to the injection.'
- B. Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia.'
- C. Human insulin prevents the development of long-term damage to the eyes and kidneys.'
- D. Human insulin does not cause the formation of antibodies because the protein structure is identical to your own.'
Correct Answer: D
Rationale: protein molecules are identical with human insulin
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
- A. Which assessment finding three hours after admission should be reported to the physician for a five-year-old with a closed head injury?
- B. The client has slight edema of the eyelids.
- C. There is clear fluid draining from the client’s right ear.
- D. There is some bleeding from the child’s lacerations.
- E. The client withdraws in response to painful stimuli.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
While monitoring the urine specific gravity of a client with a head injury, the nurse notes that the client's specific gravity is 1.004 . The most likely explanation for this finding is:
- A. The client is adequately hydrated.
- B. The client is experiencing renal failure.
- C. The client has adequate ADH secretion.
- D. The client is experiencing diabetes insipidus.
Correct Answer: D
Rationale: A low specific gravity (1.004) suggests dilute urine, common in diabetes insipidus due to impaired ADH secretion, often seen in head injuries.
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Which of the following responses by the nurse is the BEST?
- A. Do you hear voices talking to you?'
- B. Tell me why you are laughing so I can laugh too.'
- C. What is it that you find amusing?'
- D. I notice you're laughing.'
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication