Nokea
A client experiencing hallucinations.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
- A. The client sits immobilized for long periods of time.
- B. The client turns and tilts his head as if talking to someone.
- C. The client expresses the belief that the physician is out to get him.
- D. The client wrings his hands and paces constantly.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
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A client is admitted to the neurology unit for a myelogram.
It would be MOST important for the nurse to ask which of the following questions?
- A. Do you have any allergies?'
- B. Have you been drinking lots of fluids?'
- C. Are you wearing any metal objects?'
- D. Are you taking medication?'
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 90 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and confusion.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?
- A. Cheeseburger with tomato and onion.
- B. Spaghetti with meat sauce and green beans.
- C. Tuna fish sandwich with orange juice.
- D. Grilled cheese sandwich and chocolate pudding.
Correct Answer: B
Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client's plate
- D. Providing the client with child-sized utensils
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site
- B. Irrigate with 5 ml of 0.9% Normal Saline
- C. Palpate for a thrill over the fistula
- D. Check color and warmth in the extremity
Correct Answer: C
Rationale: Palpate for a thrill over the fistula. A thrill indicates patency of the fistula.