8/10/2019 53 Nclex Review

1/1

148. The nurse is caring for a 26-year-old woman immediately after deliveryof an 8 lb 4 oz baby girl. The patients history indicates she was diagnosed

with type I diabetes mellitus (IDDM) at age 12. The nurse would expect

which of the following changes to occur in the patient?

1. The blood sugar will fall due to a sudden decrease in insulin requirements.2. The blood sugar will rise due to a rapid decrease in circulating insulin.

3. The blood sugar will gradually rise due to a decreased level of metabolic stress.4. The blood sugar will gradually fall due to a decrease in food intake.

Strategy: Think about each answer choice.(1) correcthormonal interference in glucose metabolism during pregnancy causes

insulin requirements to increase then decrease after delivery(2) blood sugar will fall after delivery

(3) blood sugar level will fall after delivery(4) fall in blood sugar not primarily caused by decrease in food intake

149. In caring for a client with a nursing diagnosis of rape traumasyndrome, acute phase, the nurse should consider the MOST important

initial goal to be that

1. within three to five months, the client will state that the memory of the event isless vivid and distressing.

2. the client will indicate a willingness to keep a follow-up appointment with a rapecrisis counselor.

3. the client will be able to describe the results of the physical examination that was

completed in the emergency room.4. the client will begin to express her reactions and feelings about the assault before

leaving the emergency room.

Strategy: Think about each answer choice.(1) valid goal that needs to be addressed, but after the initial goal has been met

(2) valid goal that needs to be addressed, but after the initial goal has been met

(3) valid goal that needs to be addressed, but after the initial goal has been met(4) correctis nurses initial priority to encourage client to begin dealing with what

happened by verbalizing her feelings and gaining some acceptance and perspective

150. The nurse is leading an in-service education class on legal issues.Which of the following acts constitutes battery?

1. The nurse restrains an agitated, confused patient in the Emergency Room with a

physicians order.2. The nurse chases a patient who tries to run away while outside for a walk.

3. The nurse holds the arms of a manic patient who struck her while calling for

assistance.

4. The nurse administers an injection to a schizophrenic patient who refuses to takethe medication by mouth because he believes it is poison.

Strategy: Determine the outcome of each answer choice.(1) restraining a client to prevent injury to self or others is appropriate

(2) appropriate behavior

(3) restraining a client to prevent injury to self or others is appropriate(4) correctbattery is harmful or offensive touching of anothers person; unless court

ordered, clients have the right to refuse medication, even if client is psychotic.