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Which assessment findings would the nurse expect to document the patient's health care, and the patient's health care? Select all that apply.
- A. The client is hypertensive and tachycardic.
- B. The client is dyspneic and hypotensive.
- C. The client breathes noisily and smells of acetone.
- D. The client stares blankly and smells of alcohol.
- E. The client has warm, flushed skin and has vomited.
- F. The client complains of abdominal pain and is thirsty.
Correct Answer: C,E,F
Rationale: DKA is characterized by acetone breath, warm/flushed skin, vomiting, abdominal pain, and thirst due to hyperglycemia and dehydration.
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Which statement provides the best evidence that the client understands the prescribed drug therapy?
- A. I must take this drug after meals.
- B. I'll need to take this drug life-long.
- C. I can skip a dose if I'm nauseated.
Correct Answer: B
Rationale: Levothyroxine for myxedema typically requires lifelong therapy to maintain thyroid hormone levels.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client?
- A. Instruct the client to decrease alcohol intake.
- B. Explain the need to avoid all stress.
- C. Discuss the importance of stopping smoking.
- D. Teach the correct way to take pancreatic enzymes.
Correct Answer: A
Rationale: Decreasing alcohol intake is critical, as alcohol is a major cause of pancreatitis. Stress avoidance is unrealistic, smoking is secondary, and enzymes are for chronic cases.
The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple's procedure). Which nursing problem has the highest priority?
- A. Anticipatory grieving.
- B. Fluid volume imbalance.
- C. Alteration in comfort.
- D. Altered nutrition.
Correct Answer: B
Rationale: Fluid volume imbalance is the priority post-Whipple’s due to risks of bleeding or dehydration, impacting stability. Grieving, pain, and nutrition are secondary.
The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention?
- A. I will keep a list of my medications in my wallet and wear a Medic Alert bracelet.
- B. I should take my medication in the morning and leave it refrigerated at home.
- C. I should weigh myself every morning and record any weight gain.
- D. If I develop a tightness in my chest, I will call my health-care provider.
Correct Answer: B
Rationale: Desmopressin (DI medication) requires consistent dosing, not morning-only, and storage instructions are vague; this needs clarification. Other statements are appropriate.
Postoperatively, the nurse should consult the physician before encouraging the client who has undergone a subtotal thyroidectomy to perform which activity?
- A. Forced coughing
- B. Decompelling
- C. Ambulating
- D. Dangling legs
Correct Answer: A
Rationale: Forced coughing can increase pressure in the neck, risking bleeding or wound disruption post-thyroidectomy.