Nokea
What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
- A. Impaired Skin Integrity
- B. Knowledge Deficit: New Diabetes Diagnosis
- C. Alteration in Nutrition: More than Body Requirements
- D. Fluid Volume Deficit
Correct Answer: B
Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
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Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves while shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
- A. tachycardia and hyperthermia.
- B. bradycardia and hypothermia.
- C. a large goiter.
- D. a calm, quiet client
Correct Answer: A
Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.
A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of Glucose and Hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.
What is one characteristic of human immunodeficiency virus (HIV)?
- A. The presence of circulating antibodies that neutralize HIV is evidence of exposure to HIV.
- B. HIV replication occurs intracellularly.
- C. HIV integrates its genetic material into the host cell's DNA.
- D. DNA replication is irrelevant to HIV.
Correct Answer: C
Rationale: The correct answer is C. HIV integrates its genetic material into the host cell's DNA. The virus uses the enzyme reverse transcriptase to make a DNA copy of its RNA, which is then inserted into the genetic material of the infected cell. Choice A is incorrect because the presence of antibodies does not indicate immunity to HIV but rather exposure to the virus. Choice B is incorrect as HIV replication occurs intracellularly, inside the host cell. Choice D is irrelevant to the characteristics of HIV.
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance.
- B. When started, therapy must not be interrupted to prevent opportunistic infection.
- C. Therapy should not be interrupted for one day each month to prevent toxicity.
- D. Therapy should not be interrupted for one week every three months to prevent toxicity.
Correct Answer: A
Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.