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Question 1 of 5

A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:

Correct Answer: B

Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.

Question 2 of 5

The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to

Correct Answer: B

Rationale: dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

Question 3 of 5

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

Correct Answer: C

Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.

Question 4 of 5

One week after discharge of a postpartum client, the client's husband calls the postpartum unit and asks the nurse, 'Is it normal for my wife to cry at the drop of a hat? I'm worried I've done something to upset her.' The nurse's best initial response would be:

Correct Answer: B

Rationale: Postpartum blues are common within the first two weeks, characterized by emotional lability. Reassuring the husband while acknowledging the normalcy of this condition is appropriate.

Question 5 of 5

The client with a pacemaker should be taught to:

Correct Answer: D

Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.

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