A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At
4:30
PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
A.
Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
B.
Ask him to dissolve three pieces of hard candy in his mouth
C.
Have him drink 4 oz of orange juice
D.
Monitor him closely until dinner arrives
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
A. Gavage tube
B. Nipple and bottle
C. A straw and cup
D. Syringe
A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?
A. Hematocrit levels usually remain slightly below normalin clients with renal failure.
B. Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.
C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.
D. The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?
A. "I feel angry when I hear that tone of voice."
B. "You make me angry when you talk to me that way."
C. "Are you trying to get me angry?"
D. "Why do you treat me that way?"
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
A. Coating the inflamed areas with zinc oxide
B. Using talcum powder on the inflamed areas to promote drying
C. Removing the diaper entirely for extended periods of time
D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
A. "I know it was my fault that it happened, because I shouldn't have been out so late."
B. "If I had not worn that sexy dress that night, he wouldn't have raped me."
C. "I know my date just had so much passion he couldn't handle me saying `no.' "
D. "I know now that it was not my fault, but I want to continue counseling after my discharge."
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
A. Blood pressure
B. Level of consciousness
C. Skin turgor
D. Fluid intake
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
A. Grandiose delusions
B. Paranoid delusions
C. Auditory hallucinations
D. Visual hallucinations
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests?
A. Number of platelets
B. WBC count
C. Hemoglobin level
D. Number of lymphocytes
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
A. Urine output 22 mL/hr for 2 hours
B. Serum potassium level of 3.7
C. Small T wave of ECG
D. Serum glucose level of 180