Nokea
Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply.
- A. Systolic blood pressure, 145 mm Hg.
- B. Diastolic blood pressure, 87 mm Hg.
- C. High-density lipoprotein (HDL), 30 mg/dL.
- D. Glycosylated hemoglobin (HbA1c), 10.2%.
- E. Triglycerides, 425 mg/dL.
- F. Urine ketones, negative.
Correct Answer: A,C,D,E
Rationale: Systolic hypertension (145 mm Hg), low HDL (30 mg/dL), high HbA1c (10.2%), and elevated triglycerides (425 mg/dL) indicate poor control and cardiovascular risk, requiring reporting. Normal diastolic pressure and negative ketones are not concerning.
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An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
During the initial stage of adaptation to the diagnosis of cancer and its treatment, the nurse can facilitate the client's adaptation by:
- A. Encouraging the client to maintain her usual role.
- B. Facilitating family-related disagreements and conflicts.
- C. Supporting the client in her use of denial as a coping strategy.
- D. Arranging transportation and child care on treatment days.
Correct Answer: D
Rationale: Arranging transportation and child care addresses practical barriers, facilitating the client's ability to focus on treatment and adapt to the diagnosis.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.