Nokea
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS.
Incorrect choices:
A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax.
C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders.
D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.
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The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
- A. Type A
- B. Type AB
- C. Type B
- D. Type O
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data.
Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer.
Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer.
Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
- A. You should wear gloves when handling his linen and bedding
- B. You should keep the windows and doors closed so as not to spread the droplets
- C. He must be careful to cough into a handkerchief that is washed in hot water or discarded
- D. Make sure to boil all water before drinking or using it
Correct Answer: C
Rationale: Rationale:
Step 1: Coughing is the primary way TB bacteria are spread.
Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained.
Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading.
Step 4: This method reduces the risk of infecting family members.
Summary of Incorrect Choices:
A: Wearing gloves does not prevent airborne transmission of TB.
B: Keeping windows closed can increase the concentration of bacteria in the air.
D: Boiling water is not necessary to prevent TB transmission.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Lymphangitis is an inflammation of lymphatic vessels.
2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection.
3. Nurse should notify the physician for further evaluation and treatment.
4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification.
5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification.
6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll take a long trip to visit my aunt.”
- C. “I’ll bowl with my team after discharge.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: C
Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.