following a cva the nurse assess that a client developed dysphagia hypoactive bowel sounds and a firm distended abdomen which prescription for the cli
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1. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

Correct answer: A

Rationale: In a client with dysphagia and gastrointestinal symptoms such as hypoactive bowel sounds and a firm, distended abdomen, continuous tube feeding might exacerbate the symptoms. This can lead to complications and should be questioned by the nurse.

2. A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?

Correct answer: D

Rationale: Inadequate nutrition and decreased saliva production can lead to a conducive environment for the development of dental caries. Without proper nutrition and sufficient saliva, the protective mechanisms against cavities are compromised, making the individual more susceptible to tooth decay.

3. A 30-year-old woman presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?

Correct answer: A

Rationale: The clinical presentation of a 30-year-old woman with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is highly suggestive of type 1 diabetes mellitus. Type 1 diabetes mellitus is characterized by autoimmune destruction of pancreatic beta cells, leading to insulin deficiency and subsequent hyperglycemia. The presence of ketonuria indicates the breakdown of fats for energy due to the lack of insulin. In contrast, type 2 diabetes mellitus typically presents with gradual onset and is often associated with insulin resistance rather than absolute insulin deficiency. Diabetes insipidus is characterized by polyuria and polydipsia but is not associated with hyperglycemia or ketonuria. Hyperthyroidism may present with symptoms like fatigue but does not typically cause hyperglycemia or ketonuria.

4. A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?

Correct answer: B

Rationale: The correct action to implement first is to determine if the client received anesthesia during delivery. Anesthesia can be a potential cause of postpartum headaches. This information is crucial in assessing and managing the client's condition effectively before considering other interventions. It helps in identifying possible contributing factors to the client's complaint of a severe headache and guides the healthcare team in providing appropriate care and treatment.

5. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

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