Nokea
The nurse is caring for clients in the diabetic clinic.
Which of the following clients should the nurse see FIRST?
- A. A client with sunken eyeballs and a fruity breath odor.
- B. A client who complains of pain in his calves when he exercises.
- C. A client who states that she drinking liquids frequently and is always hungry.
- D. A client says that she is having difficulty sleeping and cries frequently.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-indicates diabetic ketoacidosis; treat with normal saline and regular insulin (2) suggestive of intermittent claudication, not an emergency situation (3) suggestive of hyperglycemia, should assess blood sugar (4) psychosocial issues, physical takes priority
You may also like to solve these questions
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
An adult is admitted with pernicious anemia. Which factor in the client's history is most likely related to the development of pernicious anemia?
- A. The client had an upper gastrointestinal (GI) bleed a year ago.
- B. The client had chemotherapy three months ago.
- C. The client had a gastrectomy six months ago.
- D. The client's mother had iron deficiency anemia
Correct Answer: C
Rationale: Gastrectomy removes the stomach's intrinsic factor-producing cells, leading to vitamin B12 malabsorption, a primary cause of pernicious anemia.
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 88 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Absence of bowel sounds.
- D. Pain rated as 6 out of 10.
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Her mother is a type I diabetic.
The nurse knows the infant is at GREATest risk for developing
- A. hypovolemia.
- B. hypoglycemia.
- C. hyperglycemia.
- D. cold stress.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice. (1) no change in blood volume for infant of diabetic mother (2) correct-fetus produces increased insulin to match mother's increased glucose level during pregnancy, infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment, increases metabolic rate, infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes, not expected with diabetic mother
The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.