Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:
The hypothalamus, when injured, can cause fluctuations and disruptions in sleep patterns.Basic Care and
Comfort
A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, ''I think my son is sexually interested in girls.'' The most appropriate course of action of the nurse is to respond by stating:
Adolescents exhibiting signs of sexual development and interest are normal.
The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth. Choices 1 and 4 are diagnoses to prevent, but no evidence suggests that they exist at this point. Diabetics might have more or less nutrition than body requirements---type II is likely to be more, but type I is likely to be less.Physiological Adaptation
Clients who take iron preparations should be warned of the possible side effects, which might include:
Oral iron preparations are often used to treat clients who have iron deficiency anemia to regain a positive iron
balance. These preparations need to be supplemented with adequate dietary intake of iron. It can take 2--3 weeks
to see improvement and up to 6--10 months to return to a stable iron level after a deficiency exists. The most
common adverse effects associated with oral iron intake are related to direct GI upset, anorexia, nausea, vomiting,
diarrhea, dark stools, and constipation. Nursing comfort measures include taking the preparations with meals,
teaching about black stools, encouragement, and proper nutrition.Physiological Adaptation
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
It is important to acknowledges the client's fear. The other responses deny the client's perceptions.
Psychosocial Integrity
Support systems during the grieving process include all of the following except:
A despondent friend, even though this could be a support to the grieving person, is in a state of despondency. Therefore, he or she might not do well with a grieving friend.Psychosocial Integrity
An assessment of the skull of a normal 10-monthold baby should identify which of the following?
The posterior fontanel should close by the age of 2 months.Health Promotion and Maintenance
The physician's role in case management includes all of the following except:
The physician is an integral part of the case-management process in terms of assisting with defining the
client's needs and the time frames for movement through the health care system; however, the physician is the expert for medical diagnosis and treatment rather than resource utilization.Coordinated Care
A patient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
The shock phase is considered the first 24-48 hours in wound management.
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept,including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.Psychosocial Integrity
Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide (HCTZ)?
The thiazide class of diuretics cause metabolic abnormalities such as elevated blood glucose levels. This elevation is caused in part by diuretic-induced potassium deficiency. Hypokalemia reduces the secretion of insulin by pancreatic beta cells, thereby increasing plasma glucose levels. Thiazides have been used for many years in clients with the conditions described in choices 1 and 2. Thiazides decrease calcium excretion, thus decreasing the likelihood of renal calculi.Pharmacological Therapies
To manage time most effectively, the nurse responds to which of the following stimuli first:
While many environmental stimuli might compete for attention and time, the client care needs of complex or unstable clients and those requiring assessment and care must take priority.Coordinated Care
The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?
Due to decreases in lean body mass, blood creatinine is not as good an indicator of the elderly client's renal function as creatinine clearance. Urinalysis and blood urea nitrogen reflect hydration status and other clues to health but are not specific for renal function. The electrolytes might be deranged in renal failure but are not a direct correlation to the kidneys' capability to eliminate waste. Therefore, the best lab for renal function in the elderly is thought to be creatinine clearance, which is a widely used test for glomerular filtration rate.Safety andInfection Control
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to
the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the
age of the child. In this example, the child is 18 months old, so the formula is 18 -- 6 = 12. An 18-month-old child
should have approximately 12 teeth.Health Promotion and Maintenance
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, ''There must be some mistake in the diagnosis.'' The nurse determines that the client is demonstrating which of the following?
Denial (Kbler-Ross's Stages of Grieving) is the refusal to believe that loss is happening.Psychosocial Integrity
