148.

The nurse is caring for a 26-year-old woman immediately after delivery

of 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.
2.
3.
4.

The
The
The
The

blood
blood
blood
blood

sugar
sugar
sugar
sugar

will
will
will
will

fall due to a sudden decrease in insulin requirements.

rise due to a rapid decrease in circulating insulin.
gradually rise due to a decreased level of metabolic stress.
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 trauma
syndrome, 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 is
less vivid and distressing.
2. the client will indicate a willingness to keep a follow-up appointment with a rape
crisis 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
(2) valid goal that needs to be addressed, but after the
(3) valid goal that needs to be addressed, but after the
(4) correctis nurses initial priority to encourage client
happened by verbalizing her feelings and gaining some

initial goal has been met

initial goal has been met
initial goal has been met
to begin dealing with what
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 take
the 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.