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1. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?
- A. Mild confusion in the morning
- B. Restlessness and agitation
- C. Incontinence
- D. Frequent wandering at night
Correct answer: B
Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.
2. What should a healthcare professional prioritize when managing a client with delirium?
- A. Administering sedative medication
- B. Providing a low-stimulation environment
- C. Identifying the underlying cause of the delirium
- D. Controlling behavioral symptoms with medication
Correct answer: C
Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.
3. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid drinking water before meals
- B. I might experience hair loss during treatment
- C. I might experience an increase in appetite
- D. I should expect my appetite to increase
Correct answer: B
Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.
4. A nurse is teaching a client who has multiple sclerosis (MS) about strategies to reduce fatigue. Which of the following instructions should the nurse include?
- A. Exercise to the point of exhaustion
- B. Rest as needed throughout the day
- C. Avoid physical activity
- D. Exercise only once per week
Correct answer: B
Rationale: The correct instruction the nurse should include is to 'Rest as needed throughout the day.' Fatigue is a common symptom of multiple sclerosis (MS), and adequate rest is essential to manage it effectively. Resting as needed helps conserve energy and prevent fatigue from worsening. Choices A, C, and D are incorrect. 'Exercise to the point of exhaustion' is not recommended as it can lead to increased fatigue. 'Avoiding physical activity' entirely is not advisable as appropriate exercise can help maintain strength and energy levels. 'Exercising only once per week' may not be sufficient to combat fatigue and maintain overall well-being in clients with MS.
5. What are the key differences between hypoglycemia and hyperglycemia?
- A. Hypoglycemia: Sweating, trembling; Hyperglycemia: Frequent urination, thirst
- B. Hypoglycemia: Increased thirst; Hyperglycemia: Sweating, confusion
- C. Hypoglycemia: Increased appetite; Hyperglycemia: Blurred vision
- D. Hypoglycemia: Dizziness; Hyperglycemia: Low blood pressure
Correct answer: A
Rationale: Hypoglycemia typically presents with sweating and trembling, while hyperglycemia is characterized by frequent urination and thirst. Therefore, the correct key differences between hypoglycemia and hyperglycemia are that hypoglycemia includes symptoms like sweating and trembling, while hyperglycemia involves symptoms such as frequent urination and thirst. Choices B, C, and D are incorrect because they do not accurately represent the characteristic symptoms of hypoglycemia and hyperglycemia, as stated in the question.
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