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1. What are the signs of hypoglycemia, and how should a healthcare provider respond to a patient experiencing this condition?
- A. Shakiness or Tremors
- B. Confusion or Irritability
- C. Hunger
- D. Dizziness or Lightheadedness
Correct answer: A
Rationale: The signs of hypoglycemia include shakiness, confusion, hunger, dizziness, and lightheadedness. However, the classic and most common early sign is shakiness or tremors. When a patient is experiencing hypoglycemia, a healthcare provider should respond promptly by administering glucose to raise the blood sugar levels. Choice A is correct as it directly addresses one of the primary signs of hypoglycemia. Choices B, C, and D are incorrect because while confusion, irritability, hunger, dizziness, and lightheadedness can also be signs of hypoglycemia, shakiness or tremors are the classic and most common early symptoms that healthcare providers should be particularly vigilant for.
2. A client post-lumbar puncture should be in which position?
- A. High Fowler's position
- B. Prone position
- C. Supine position
- D. Sitting position
Correct answer: C
Rationale: The most appropriate position for a client post-lumbar puncture is the supine position. Placing the client in a supine position helps prevent spinal headaches by allowing the puncture site to seal effectively and reducing the risk of cerebrospinal fluid leakage. High Fowler's position, prone position, and sitting position are not recommended after a lumbar puncture as they may increase the risk of complications like spinal headaches.
3. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?
- A. Amnesia
- B. Hypervigilance
- C. Hallucinations
- D. Severe agitation
Correct answer: B
Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.
4. A client has a new diagnosis of Raynaud's disease. Which of the following instructions should the nurse include?
- A. Increase your intake of foods high in potassium.
- B. Keep your home environment warm.
- C. Elevate your legs when sitting.
- D. Reduce your intake of sodium.
Correct answer: B
Rationale: The correct answer is to keep the home environment warm. Raynaud's disease causes vasospasm in response to cold, so maintaining a warm environment can help prevent attacks. Choices A, C, and D are incorrect. Increasing potassium intake, elevating legs when sitting, or reducing sodium intake are not specific to managing Raynaud's disease.
5. How should a healthcare professional assess and manage a patient with dehydration?
- A. Assess skin turgor and monitor intake/output
- B. Encourage oral fluids only
- C. Administer IV fluids immediately
- D. Check for electrolyte imbalance and administer fluids
Correct answer: A
Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.
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