Nokea
Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
- A. Sweating
- B. Tremors
- C. Pallor
- D. Thirst
Correct Answer: D
Rationale: The correct answer is D: Thirst. Hyperglycemia results in elevated blood sugar levels, leading to increased osmolality and dehydration, triggering thirst as the body attempts to dilute the blood. Sweating (A), tremors (B), and pallor (C) are not typically associated with hyperglycemia. Sweating is more commonly seen in hypoglycemia, tremors can be a sign of low blood sugar, and pallor is not a direct symptom of high blood sugar levels.
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Which of the following actions should the nurse take first?
- A. Ask the client if he is considering harming himself.
- B. Encourage the client to attend a group therapy session.
- C. Administer an antidepressant to the client.
- D. Assist the client in completing his ADLs.
Correct Answer: A
Rationale: The correct answer is A. Asking the client if he is considering harming himself should be the first action because it assesses the client's immediate safety. This step is crucial in identifying any potential suicidal ideation and implementing appropriate interventions to ensure the client's well-being. Encouraging group therapy (B), administering medication (C), and assisting with ADLs (D) are important interventions but should come after addressing the client's safety concerns. It is essential to prioritize actions that address the most critical needs first to provide effective and timely care.
Which of the following actions should the nurse take?
- A. Administer chlorothiazide.
- B. Hold the child down.
- C. Place the child in a prone position.
- D. Time the episode.
Correct Answer: D
Rationale: The correct action is D: Time the episode. By timing the episode, the nurse can gather important data to assess the duration and severity of the situation, aiding in diagnosis and treatment planning. Administering chlorothiazide (A) without assessing the situation first could be harmful. Holding the child down (B) may escalate the situation and cause distress. Placing the child in a prone position (C) could worsen their condition. Timing the episode (D) is essential for accurate evaluation.
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.
Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.