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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 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.
3. What are the nursing considerations for a patient receiving anticoagulant therapy?
- A. Monitor INR levels and check for bleeding
- B. Educate patient on dietary restrictions
- C. Ensure adequate hydration and nutrition
- D. Ensure that the patient remains immobile
Correct answer: A
Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.
4. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?
- A. Confusion and disorientation that resolve with rest
- B. A blood pressure reading of 110/70
- C. Irritability and agitation that worsen throughout the day
- D. Mild confusion during the evening hours
Correct answer: C
Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.
5. A client with active tuberculosis is receiving discharge instructions. Which statement by the client indicates an understanding of the teaching?
- A. I will continue taking my isoniazid until I am no longer contagious.
- B. I should take my prescribed medication for at least 6 months.
- C. I will need to have a TB skin test every 3 months.
- D. I should wear a mask at all times.
Correct answer: B
Rationale: The correct answer is B because the client should take antitubercular medications for a minimum of 6 months to ensure complete eradication of the infection. Choice A is incorrect as stopping the medication early can result in treatment failure and development of drug-resistant TB. Choice C is incorrect as regular TB skin tests are not needed once the client has been diagnosed and treated. Choice D is incorrect as wearing a mask at all times is not necessary for a client with active TB; proper cough etiquette should be followed instead.
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