Nursing Elites

1. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

2. What are the nursing interventions for a patient experiencing hypoglycemia?

• A. Administer glucose or dextrose and monitor blood sugar levels
• B. Monitor vital signs and provide a high-carbohydrate snack
• C. Monitor for sweating and confusion
• D. Provide insulin and assess for hyperglycemia

Correct answer: A

Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.

3. What are the signs of hypoglycemia, and how should they be managed?

• A. Sweating, trembling; administer glucose
• B. Headache, confusion; administer insulin
• C. Dizziness, fatigue; administer glucose
• D. Increased heart rate; provide a high-sugar snack

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

4. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

• A. Provide clear instructions on how to ask for assistance
• B. Gradually resume self-care tasks, focusing on rest periods
• C. Encourage assistive personnel to complete self-care tasks
• D. Encourage the client to remain in bed until fully rested

Correct answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

5. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?

• A. Polyuria.
• B. Dehydration.
• C. Hyponatremia.
• D. Hyperglycemia.

Correct answer: C

Rationale: The correct answer is C: Hyponatremia. In SIADH, there is excessive release of antidiuretic hormone, causing water retention and dilutional hyponatremia. Polyuria (choice A) is increased urination, which is not a typical finding in SIADH. Dehydration (choice B) is the loss of body fluids, which is opposite to the fluid retention seen in SIADH. Hyperglycemia (choice D) is elevated blood sugar levels and is not directly related to SIADH.

Similar Questions