Nokea
The patient is admitted to the emergency department and was brought to the unit due to poor diabetic management. The wife asks how they can learn better. They have previously been to a diabetic class without much success.
Which of the following nursing strategy will be appropriate for the client?
- A. Arrange a meeting with the health care team.
- B. Have a one-on-one diabetic teaching with the client.
- C. Refer the client and wife to group diabetic teaching class.
- D. Discuss the possibility of having to stay longer in the unit to manage the blood sugar.
Correct Answer: B
Rationale: One-on-one teaching allows tailored education to address specific learning needs.
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The nurse is caring for a client with a history of bipolar disorder who is prescribed lithium. Which of the following laboratory values should the nurse monitor?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum calcium.
- D. Serum hemoglobin.
Correct Answer: A
Rationale: Lithium can cause hyponatremia, and monitoring serum sodium ensures safe levels (therapeutic lithium range: 0.6–1.2 mEq/L). Glucose (B), calcium (C), and hemoglobin (D) are not directly affected by lithium therapy.
When teaching a mother about communicable diseases
When teaching a mother about communicable diseases, the nurse informs her that chickenpox is:
- A. Still communicable until all the vesicles have dried.
- B. Still communicable even when just dried scabs remain.
- C. No longer communicable after a high fever has subsided.
- D. Not communicable as long as the vesicles are intact and surrounded by a red areola.
Correct Answer: A
Rationale: Chickenpox is communicable until all vesicles have crusted over.
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?
- A. TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30
- B. It can occur in clients taking antipsychotic drugs longer than 2 years
- C. Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible
- D. TD can easily be treated with anticholinergic drugs
Correct Answer: B
Rationale: Tardive dyskinesia is an extrapyramidal side effect that typically develops after prolonged use of antipsychotic drugs, often longer than 2 years, and is not easily reversible or treated with anticholinergics.
Which of the following clients is at greatest risk for postpartal hemorrhage?
- A. A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
- B. A gravida 1 para 0 with a history of polycystic ovarian disease
- C. A gravida 2 para 2 with a history of low birth weight infants
- D. A gravida 4 para 3 with a Caesarean section
Correct Answer: D
Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for postpartal hemorrhage due to multiparity and surgical delivery, which can lead to uterine atony and increased bleeding risk.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.