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1. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?
- A. A Braden scale score of 20
- B. An albumin level of 3 g/dL
- C. A hemoglobin level of 13 g/dL
- D. A Norton scale score of 18
Correct answer: B
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.
2. What are the early signs of hypoglycemia in a diabetic patient?
- A. Sweating and trembling
- B. Confusion and irritability
- C. Dizziness and increased heart rate
- D. Nausea and vomiting
Correct answer: A
Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.
3. A client is constipated and asks the nurse for advice. What should the nurse recommend?
- A. Administer a laxative to relieve discomfort
- B. Increase dietary fiber to promote bowel movements
- C. Advise the client to rest until symptoms resolve
- D. Encourage bed rest to allow bowel function to return
Correct answer: B
Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.
4. What lifestyle change should be emphasized for a client with hypertension?
- A. Increase intake of dairy products
- B. Reduce caffeine and sodium intake
- C. Eat carbohydrate-rich meals
- D. Limit intake of leafy green vegetables
Correct answer: B
Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.
5. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?
- A. Ask the client to discuss their feelings
- B. Explain the importance of the medications
- C. Document the refusal and withhold the medication
- D. Inform the client of the possible consequences of refusal
Correct answer: D
Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.
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