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1. What are the key signs of hyperglycemia?
- A. Increased thirst and frequent urination
- B. Decreased appetite and low blood pressure
- C. Weight loss and nausea
- D. Increased sweating and confusion
Correct answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.
2. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN - 25, K+ - 4.0 mEq/L. Which nutrient should be restricted in the client's diet?
- A. Protein
- B. Fats
- C. Carbohydrates
- D. Magnesium
Correct answer: A
Rationale: In clients with oliguria, hypertension, and peripheral edema, protein should be restricted in the diet to reduce the workload on the kidneys. Excessive protein intake can lead to increased BUN levels, which can further stress the kidneys. Restricting protein can help prevent further kidney damage. Fats, carbohydrates, and magnesium do not directly impact kidney function in the same way as protein does, making them incorrect choices in this scenario.
3. What are the signs and symptoms of Cushing's syndrome, and how should they be managed?
- A. Weight gain, moon face; administer corticosteroids
- B. Hirsutism and thin extremities; manage with diuretics
- C. Purple striae, muscle weakness; provide dietary counseling
- D. Hypertension and bruising; manage with fluid restriction
Correct answer: A
Rationale: The correct signs and symptoms of Cushing's syndrome are weight gain and a moon face. Corticosteroids are used to manage Cushing's syndrome by reducing the overproduction of cortisol. Choice B is incorrect because hirsutism and thin extremities are not typical signs of Cushing's syndrome. Choice C is incorrect as purple striae and muscle weakness are more characteristic of the syndrome. Choice D is also incorrect as hypertension and bruising are not primary signs of Cushing's syndrome.
4. A nurse is reviewing the record of a client with dementia. Which of the following findings should the nurse prioritize?
- A. Wandering at night
- B. A serum albumin level of 3.5 g/dL
- C. Urinary incontinence
- D. Restlessness and agitation
Correct answer: D
Rationale: Restlessness and agitation in clients with dementia could indicate a worsening condition and should be prioritized. While wandering at night and urinary incontinence are common issues in dementia patients, restlessness and agitation can signal acute distress or an unmet need, requiring immediate attention. Monitoring serum albumin levels is important for overall health but would not be the priority when assessing a client with dementia.
5. What is the nurse's responsibility when managing a physically assaultive client?
- A. Restrict the client to the room
- B. Place the client under one-to-one supervision
- C. Restore the client's self-control
- D. Clear the area of other clients
Correct answer: C
Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.
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