Silvestri, 3/e, ISBN 1-1460-0052-6Unit XV (edited file)—"Comprehensive Test”10/14/08, Page 2 of 46, 0 Figure(s), 0 Table(s), 0 Box(es)
question was difficult, review this medication.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: PharmacologyReference: Hodgson, B., & Kizior, R. (2005).
Saunders nursing drug handbook 2005
.Philadelphia: W.B. Saunders, p. 970.3. A client is admitted to the hospital with a diagnosis of major depression. The nurse collectsdata on the client and determines that a major concern is the client’s altered nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this concern is:1. Explain to the client the importance of a good nutritional intake.2. Weigh the client three times per week, before breakfast.3. Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible.4. Consult with the nutritionist, offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.Answer: 4Rationale: Change in appetite is one of the major symptoms of depression. Offering the clientseveral small, frequent meals and the nurse’s presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. The client is experiencing poor concentration and will not understand the importance of an adequate nutritional intake.Weighing the client does not address how to increase nutritional intake. Reporting the nutritional problems to the psychiatrist is to some degree correct, but doesn’t address how one mightincrease food intake.Test-Taking Strategy: Use the process of elimination and focus on the issue, the poor nutritionalintake. Option 4 is the only option that addresses the altered nutrition concretely and designs amethod in which the client will feasibly increase the nutritional intake. Review care of the clientwith depression if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthReference: Morrison-Valfre, M. (2005).
Foundations of mental health care
(3rd ed.). St. Louis:Mosby, p. 215.4. A client received 20 units of NPH insulin subcutaneously at 8 a.m. The nurse should check the client for a hypoglycemic reaction at:1. 10 a.m.2. 11 a.m.3. 5 p.m.4. 11 p.m.Answer: 3Rationale: NPH is an intermediate-acting insulin. Its onset of action is 1 to 2 hours, it peaks in6 to 14 hours, and its duration of action is 24 hours. Hypoglycemic reactions most likely occur