Nokea
The nurse writes a problem of "potential for complication related to ovarian hyperstimulation" for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?
- A. Instruct the client to delay intercourse until menses
- B. Schedule the client for frequent pelvic sonograms
- C. Explain that the infusion therapy will take 21 days
- D. Discuss that this may cause an ectopic pregnancy
Correct Answer: B
Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (Choice A) is not directly related to monitoring for ovarian hyperstimulation. Explaining the duration of infusion therapy (Choice C) is not relevant to monitoring for this specific complication. Discussing the risk of ectopic pregnancy (Choice D) is important, but it is not the most appropriate intervention for monitoring ovarian hyperstimulation.
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The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?
- A. The islet cells in the pancreas stop producing insulin
- B. The client eats too many foods that are high in sugar
- C. The pituitary gland does not produce vasopressin
- D. The cells become resistant to the circulating insulin
Correct Answer: D
Rationale: In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect as in Type 1 diabetes the islet cells in the pancreas stop producing insulin. Choice B is incorrect as while excessive sugar intake can contribute to the development of Type 2 diabetes, it is not the primary cause. Choice C is incorrect as the pituitary gland's function is unrelated to the development of Type 2 diabetes.
The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client in ambulating
- B. Assess the client's bilateral pedal pulses
- C. Maintain a continuous IV heparin drip
- D. Provide clear liquids to the client
Correct Answer: B
Rationale: Assessing the client's bilateral pedal pulses is crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (Choice A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (Choice C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (Choice D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.
Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task 'Know what your soldiers are doing during duty hours'?
- A. Accountability
- B. Personal/professional development
- C. Individual training
- D. Military appearance/physical condition
Correct Answer: A
Rationale: The correct answer is 'Accountability.' This choice is the most appropriate for the task 'Know what your soldiers are doing during duty hours' as it directly relates to being responsible for and knowing the actions and whereabouts of individuals under supervision. 'Personal/professional development' (choice B) focuses on growth and advancement, 'Individual training' (choice C) pertains to specific skill development, and 'Military appearance/physical condition' (choice D) deals with the physical presentation and health of soldiers, none of which directly address the task of knowing soldiers' activities during duty hours.
In determining and fulfilling the nursing care needs of the patient, which step involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: A
Rationale: The correct answer is A, 'Evaluation.' Evaluation in nursing involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status. This step helps determine the outcomes of the care provided and if any changes are needed. Choice B, 'Planning,' focuses on developing a plan of care based on the assessment findings. Choice C, 'Implementation,' involves carrying out the plan of care. Choice D, 'Assessment,' is the initial step in the nursing process that involves gathering data about the patient's health status.
During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A
Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.