Nokea
The physician orders an MRI of the spine with infusion for an adult female. Which of the following findings in the client's history should the nurse report to the physician?
- A. allergy to shellfish
- B. congestive heart failure (CHF)
- C. chronic cystitis
- D. metformin administered daily
Correct Answer: A
Rationale: Shellfish allergy may indicate iodine sensitivity, a concern for MRI contrast, requiring physician evaluation to prevent allergic reactions.
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The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
- A. The client selects a balanced diet from the menu.
- B. The client can tell the nurse the normal blood glucose level.
- C. The client asks for brochures on the subject of diabetes.
- D. The client demonstrates correct insulin injection technique.
Correct Answer: D
Rationale: Demonstrating correct insulin injection technique indicates practical understanding and ability to manage diabetes effectively.
The nurse is working with a client in the psychiatric unit. The client has memory gaps, which she fills in with detailed fantasies that she believes to be true. The nurse understands that the client is exhibiting which type of abnormal thought process?
- A. Delusion
- B. Confabulation
- C. Tangentiality
- D. Flight of ideas
Correct Answer: B
Rationale: Confabulation involves filling memory gaps with fabricated details believed to be true, common in certain psychiatric or neurological conditions.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
A 22-year-old woman has just been diagnosed with myasthenia gravis. She asks the nurse what causes this disease. The most accurate response from the nurse is
- A. This is a disease caused by a chromosomal defect in utero. It is a structural abnormality in the chromosome that causes nerve cells in your body to become inflamed and not function properly.'
- B. This is an autoimmune disease in which antibodies attack the muscles and muscle atrophy occurs. The muscles will become weak and begin to waste.'
- C. This is an autoimmune disease in which antibodies destroy acetylcholine at the neuromuscular junction. This prevents your muscles from contracting normally.'
- D. This is a hereditary condition caused by a recessive gene. It causes nervous tissue to be broken down, and damage occurs to the brain and spinal cord.'
Correct Answer: C
Rationale: Myasthenia gravis is an autoimmune disorder where antibodies attack acetylcholine receptors at the neuromuscular junction, impairing muscle contraction.
Each staff person has an individual password that allows access to electronic health records. Under which of the following circumstances should a nurse allow another staff person to use his/her password?
- A. A physician asks to use the password to access records of a former client.
- B. Another nurse asks to use the password because he has forgotten his own.
- C. The nurse's supervisor asks to use the password to access client records.
- D. The nurse should not allow anyone else to use the password, regardless of circumstances.
Correct Answer: D
Rationale: Passwords must not be shared (D) to protect patient confidentiality and comply with HIPAA. Sharing with a physician (A), nurse (B), or supervisor (C) is unauthorized.