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Questions 163

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Question 1 of 5

A client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?

Correct Answer: A

Rationale: Nausea, abdominal pain, and thirst in a TPN client suggest hyperglycemia, so checking blood glucose is the best action. Vital signs , reporting , or slowing infusion are secondary without glucose confirmation.

Question 2 of 5

A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present

Correct Answer: B

Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.

Question 3 of 5

What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.

Correct Answer: B,C,D

Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.

Question 4 of 5

At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?

Correct Answer: C

Rationale: Sit without support. This is a typical developmental milestone for an 8-month-old.

Question 5 of 5

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers?

Correct Answer: B

Rationale: The priority outcome for caregivers of a child with type 1 diabetes is knowing how to keep blood sugars stable , as this directly impacts the child's health and prevents complications. Coping , meal planning , and follow-up are important but secondary.

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