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1. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?
- A. My son took my wallet to keep track of my spending
- B. My son always cooks my meals for me
- C. My son doesn't want me to drive alone
- D. I exercise every day with my son
Correct answer: A
Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.
2. A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?
- A. Fatigue
- B. Constipation
- C. Hair loss
- D. Weight gain
Correct answer: A
Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.
3. A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?
- A. Constipation
- B. Absent deep-tendon reflexes
- C. Nausea and vomiting
- D. Tingling of the extremities
Correct answer: D
Rationale: Correct! A calcium level of 8.0 mg/dL indicates hypocalcemia. Hypocalcemia can lead to increased neuromuscular excitability, manifesting as tingling of the extremities. Choices A, B, and C are incorrect findings associated with other electrolyte imbalances or conditions and are not typically related to hypocalcemia. Constipation is commonly seen in hypokalemia, absent deep-tendon reflexes are associated with hypermagnesemia, and nausea and vomiting are more indicative of hypercalcemia.
4. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?
- A. Weight gain
- B. Poor appetite
- C. Irritability
- D. Decreased urination
Correct answer: C
Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.
5. How should a healthcare provider manage a patient with Type 1 diabetes?
- A. Administer insulin and monitor blood glucose levels
- B. Provide a low-carbohydrate diet and oral hypoglycemics
- C. Administer oral hypoglycemics and provide dietary education
- D. Provide a high-protein diet and insulin injections
Correct answer: A
Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.
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