A nurse would expect a newly diagnosed insulin-dependent diabetic to exhibit which clinical manifestations?
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Solution
Answer D is correct. The three main symptoms of diabetes are increased urination, increased thirst, and increased appetite. Answer A is incorrect because the client’s appetite would be increased. Diabetics experience weight loss, which makes answer B incorrect. Answer C is not associated with diabetes.
The nurse caring for a client with Alzheimer’s disease should initiate which of the following when requesting an action by the client?
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Solution
Answer B is correct. The nurse should give only one direction or step at a time when communicating to clients with Alzheimer’s disease. Clients cannot comprehend when too much detailed information or too many instructions are given at one time, making answers A and D incorrect. Answer C forces the Alzheimer’s client to make a choice and a decision, which is difficult for clients with this disorder.
A client is admitted with hypothyroidism. Which clinical manifestation would the nurse expect the client to exhibit?
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Solution
Answer B is correct. These clients have a subnormal temperature and pulse rate, causing them to have a decreased tolerance of cold. Answers A, C, and D are symptoms of hyperthyroidism, so they are incorrect.
A client with suspected myasthenias gravis has been administered the drug edrophonium chloride (Tensilon). Which effect would the nurse expect the client to exhibit after administration?
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Solution
Answer C is correct. Clients with myasthenia gravis have a decrease in muscular strength because of a lack of acetylcholine. Tensilon administration halts the breakdown of acetylcholine, causing an increase in muscular strength that confirms the diagnosis. Answer A would indicate that the client does not have myasthenias gravis. Answers B and D are not an effect of the drug Tensilon.
The nurse is providing initial first aid for a client with thermal burn injury in a community setting. Which action is appropriate?
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Solution
Answer C is correct. Cooling the burn stops the burn process, relieving pain and limiting edema. This is the initial action. Answers A and B are not initial actions to be performed in the field. Adherent clothing should remain in place after being cooled, so answer D is incorrect.
A client who is in end-stage cirrhosis should restrict which of these foods?
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Solution
Answer C is correct. With clients who are in end-stage cirrhosis, proteins are restricted because of the inability of the liver to convert the protein for excretion. This results in build-up of ammonia in the body. Answers A, B, and D are not restricted foods.
The nurse is reinforcing teaching to a client with a hiatal hernia. Which would be included in the teaching plan?
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Solution
Answer C is correct. Remaining upright will decrease the chance of esophageal reflux. Clients should avoid fatty foods, coffee, tea, cola, chocolate, alcohol, and spicy and acidic foods, which makes answers B and D incorrect. Puréed diets, as in answer A, are not recommended.
What teaching should the nurse reinforce to a young male adult regarding when he should perform testicular self-examinations?
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Solution
Answer B is correct. This is the American Cancer Society’s recommendation for testicular examination. Answers A, C, and D are not the correct timing sequences for a testicular examination.
A client with a hip fracture is receiving heparin sub-cutaneously. Which laboratory test should the nurse monitor when administering this medication?
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Solution
Answer C is correct. aPTTs should be monitored on clients receiving heparin. The goal is 1.5 to 2 times the control for prevention of deep vein thrombosis. Answer A is used for the monitoring of Coumadin therapy. Answer B is the antidote for too much Coumadin. Answer D is not a test used for heparin or Coumadin.
A client is returning to the room after a thyroidectomy. Which piece of equipment should the nurse place at the bedside?
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Solution
Answer A is correct. A tracheotomy set is placed at the bedside as a safety measure in case the client has severe edema or respiratory distress. The pieces of equipment in answers B, C, and D are not required or helpful after a thyroidectomy.