43.

A client with newly diagnosed type I diabetes mellitus is being seen by

the home health nurse. The physician orders include: 1,200-calorie ADA
diet, 15 units of NPH insulin before breakfast, and check blood sugar qid.
When the nurse visits the client at 5 PM, the nurse observes the man
performing a blood sugar analysis. The result is 50 mg/dL. The nurse would
expect the client to be
1.
2.
3.
4.

confused with cold, clammy skin and a pulse of 110.

lethargic with hot, dry skin and rapid, deep respirations.
alert and cooperative with a BP of 130/80 and respirations of 12.
short of breath, with distended neck veins and a bounding pulse of 96.

Strategy: Determine the cause of each answer choice.

(1) correctsymptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
(2) symptoms of hyperglycemia, blood sugar above 110 mg/dL
(3) normal appearance and vital signs
(4) symptoms of fluid overload caused by CHF, rapid infusion of IV fluids
44. The nurses INITIAL priority when managing a physically assaultive
client is to
1.
2.
3.
4.

restrict the client to the room.

place the client under one-to-one supervision.
restore the clients self-control and prevent further loss of control.
clear the immediate area of other clients to prevent harm.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) time out or room restriction might be a useful strategy before the client becomes
assaultive; once client is assaultive, s/he may continue this behavior in his/her room
without any redirection and support
(2) may not stop assaultive behavior
(3) correctmost important priority in the nursing management of an assaultive
client is to maintain milieu safety by restoring the clients self-control; a quick
assessment of situation, psychological intervention, chemical intervention, and
possibly physical control are important when managing the physically assaultive
client
(4) is helpful, but may not be realistic if the situation escalates quickly
45. The nurse observes a LPN/LVN perform a wet-to-dry dressing change on
a 2-inch abdominal incision. Which of the following behaviors, if performed
by the LPN/LVN, would indicate an understanding of proper technique?
1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of
the incision using long strokes.
2. The incision is packed with sterile gauze, and then sterile saline is poured over the
dressing.
3. The nurse packs wet gauze into the incision without overlapping it onto the skin.
4. The old dressing is saturated with sterile saline before it is removed.