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Questions 158

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Extract:


Question 1 of 5

A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:

Correct Answer: C

Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.

Question 2 of 5

Priapism may be a sign of:

Correct Answer: A

Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.

Question 3 of 5

Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?

Correct Answer: A

Rationale: These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. As long as the meat has not been aged or smoked, it is within the dietary regimen. Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.

Question 4 of 5

The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?

Correct Answer: D

Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.

Question 5 of 5

The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

Correct Answer: A

Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.

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