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Question 1 of 5

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

Correct Answer: C

Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.

Question 2 of 5

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

Correct Answer: C

Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.

Question 3 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 4 of 5

A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, 'I haven't exercised in 6 days. I won't be eating lunch today.' This statement by her most likely reflects:

Correct Answer: A

Rationale: Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted.

Question 5 of 5

The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

Correct Answer: A

Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.

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