Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
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Which client statement should the nurse report as an indication of major depressive disorder?
- A. I am unable to feel any joy since my child died
- B. I have lost interest in activities I once enjoyed.
- C. I have trouble sleeping and have no appetite.
- D. I feel guilty and worthless every day.
- E. I have been thinking about ending my own life.
Correct Answer: E
Rationale: The correct answer is E because suicidal ideation is a significant red flag for major depressive disorder. This statement indicates severe emotional distress and potential risk for self-harm. Choices A, B, C, and D are common symptoms of depression but do not necessarily point to the severity and immediate risk of suicide like choice E does. Reporting suicidal thoughts is crucial for timely intervention and ensuring the client's safety.
Which of the following findings should the nurse expect?
- A. Reduce right sided breath sounds
- B. Inter coastal retractions
- C. High pitched strider
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not characteristic of pneumothorax.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
Which task should the nurse perform to practice distributive justice?
- A. Ensuring that a client who is homeless receives preventative medical care
- B. Allocating community resources fairly among all clients in need.
- C. Prioritizing care for clients based on medical necessity rather than financial status.
- D. Advocating for equal access to healthcare services for underserved populations.
- E. Developing programs that address social determinants of health to reduce disparities.
Correct Answer: E
Rationale: The correct answer is E because developing programs that address social determinants of health to reduce disparities aligns with the principle of distributive justice, which focuses on fair distribution of resources to reduce inequalities. By addressing social determinants of health, such as income inequality or access to education, the nurse is working towards creating equal opportunities for all individuals to achieve good health outcomes.
Choices A, B, C, and D do not directly address the root causes of health disparities and inequality. Option A focuses on providing care to a specific individual rather than addressing systemic issues. Option B talks about allocating resources fairly but lacks the focus on addressing social determinants. Option C mentions prioritizing care based on medical necessity, which may not necessarily target disparities. Option D discusses advocating for equal access, but it does not specifically address the underlying social determinants that contribute to inequalities.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.