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Questions 164

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Extract:


Question 1 of 5

The nurse is collecting data from a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?

Correct Answer: C

Rationale: Hyperemesis gravidarum causes severe vomiting, leading to dehydration and starvation, resulting in ketosis. Positive ketones in urinalysis confirm this metabolic state.

Question 2 of 5

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

Correct Answer: C

Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.

Question 3 of 5

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?

Correct Answer: C

Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.

Question 4 of 5

During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

Correct Answer: D

Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.

Extract:

Intake and output record
Time Oral intake Parenteral intake Output
0700 180 mL juice
0800 1 L 0.9% sodium chloride IV 150 mL liquid stool
1000 75 mL vancomycin
1200 240 mL tea 250 mL metronidazole IV
1500 360 mL water
1600 1300 mL urine from collection bag


Question 5 of 5

The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.

Correct Answer: 655 mL

Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL

Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL

Total Output = 1450 mL

3. Net Balance:
2105 − 1450 = 655 mL net positive balance

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