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Questions 158

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Question 1 of 5

The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?

Correct Answer: C

Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.

Question 2 of 5

One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:

Correct Answer: B

Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.

Question 3 of 5

A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

Correct Answer: B

Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.

Question 4 of 5

Which of the following nursing care goals has the highest priority for a child with epiglottitis?

Correct Answer: A

Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.

Question 5 of 5

The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?

Correct Answer: C

Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.

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