Nokea
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
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As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
- A. Assist the client to develop a daily bowel routine to prevent constipation.
- B. Teach the client to manage emotional stressors by using mental imaging.
- C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
- D. Administer dexamethasone orally per the primary health care provider's prescription.
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation should the nurse monitor the client for? Select all that apply.
- A. Pallor
- B. Dizziness
- C. Diaphoresis
- D. Bradycardia
- E. Constipation
- F. Extreme thirst
Correct Answer: A,B,C
Rationale: Dumping syndrome is the rapid emptying of the gastric contents into the small intestine that occurs after gastric resection. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Manifestations also include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
- A. The delay of the impending death
- B. Offering a caring support system
- C. Providing measure focused on pain management
- D. Introduction of interventions that enhance the quality of life
- E. Expanding the focus of care to both the client and the family
- F. Addressing the expressed spiritual needs of the client and the family
Correct Answer: B,C,D,E,F
Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: offering a support system to help the client live as actively as possible until death; providing relief from pain and other distressing symptoms; enhancing the quality of life; offering a support system to help families cope during the client's illness and their own bereavement; affirming life and regarding dying as a normal process, neither hastening nor postponing death; and integrating psychological and spiritual aspects of client care.
A client diagnosed with chronic kidney disease is prescribed epoetin alfa. When discussing measures needed to support this medication therapy, the nurse should include information regarding which supplement?
- A. Iron
- B. Zinc
- C. Calcium
- D. Magnesium
Correct Answer: A
Rationale: Epoetin alfa is a hematopoietic agent used to stimulate red blood cell production in clients with anemia, such as those with chronic kidney disease. Iron supplementation is necessary to support this therapy because adequate iron stores are required for effective erythropoiesis. Without sufficient iron, the effectiveness of epoetin alfa is reduced. Zinc, calcium, and magnesium are not directly related to supporting red blood cell production in this context.