Nokea
When managing a physically assaultive client, the nurse's INITIAL priority is to
- A. Restrict the client to the room
- B. Place the client under one-to-one supervision
- C. Restore the client's self-control and prevent further loss of control
- D. Clear the immediate area of other clients to prevent harm
Correct Answer: C
Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.
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A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin A1c of 6%
- B. Fasting blood glucose of 90 mg/dL
- C. Blood glucose of 200 mg/dL
- D. Blood glucose of 100 mg/dL
Correct Answer: C
Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.
What are the signs of hypoglycemia, and how should they be managed?
- A. Sweating, trembling; administer glucose
- B. Headache, confusion; administer insulin
- C. Dizziness, fatigue; administer glucose
- D. Increased heart rate; provide a high-sugar snack
Correct Answer: A
Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.
A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?
- A. Haloperidol
- B. Zolpidem
- C. Morphine
- D. Lorazepam
Correct Answer: B
Rationale: The correct answer is B: Zolpidem. Zolpidem is a sedative-hypnotic medication that can worsen altered mental status, especially in clients who are already aggressive. Therefore, the nurse should clarify this prescription with the provider before administration to ensure it is safe for the client.
Choice A, Haloperidol, is an antipsychotic commonly used to manage aggression in clients with altered mental status, making it an appropriate choice in this scenario. Choice C, Morphine, is an opioid analgesic and would not directly impact the client's altered mental status or aggression. Choice D, Lorazepam, is a benzodiazepine used to manage anxiety and agitation, which could be beneficial in this situation but does not have the same potential to exacerbate altered mental status as Zolpidem.
A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?
- A. Cabbage
- B. Bananas
- C. Carrots
- D. Potatoes
Correct Answer: B
Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.
Which intervention is essential when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink water throughout the day
- B. Monitor the client's weight daily to assess fluid balance
- C. Limit fluid intake during meals
- D. Weigh the client once a week to assess fluid balance
Correct Answer: B
Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.