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The pediatric nurse specialist teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease?
- A. Pain
- B. Nuchal rigidity
- C. Impaired hearing
- D. A red swollen testicle
Correct Answer: B
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication.
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The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
A client experiencing a severe major depressive episode is unable to address activities of daily living (ADL). Which nursing intervention best meets the client's current needs therapeutically?
- A. Have the client's peers approach the client about how noncompliance in addressing ADL affects the milieu.
- B. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADL.
- C. Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining her or his own ADL.
- D. Feed, bathe, and dress the client as needed until the client's condition improves so that she or he can perform these activities independently.
Correct Answer: D
Rationale: The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations.
A client is diagnosed with cholecystitis. The nurse reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.
- A. Dyspepsia
- B. Dark stools
- C. Light-colored and clear urine
- D. Feelings of abdominal fullness
- E. Rebound tenderness in the abdomen
- F. Upper abdominal pain that radiates to the right shoulder
Correct Answer: A,D,E,F
Rationale: Cholecystitis is an inflammation of the gallbladder. Manifestations include dyspepsia; feelings of abdominal fullness; rebound tenderness (Blumberg's sign); upper abdominal pain or discomfort that can radiate to the right shoulder; pain triggered by a high-fat meal; clay-colored stools, dark urine, and possible steatorrhea; anorexia, nausea, and vomiting; eructation; flatulence; fever; and jaundice.
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness?
- A. Monitor the client's weight.
- B. Monitor the client's intake and output.
- C. Calculate the client's daily caloric intake.
- D. Frequently check the client's serum protein levels.
Correct Answer: A
Rationale: The most accurate measurement of weight loss is weighing of the client. This should be done at the same time of the day, in the same clothes, and using the same scale. Options 2, 3, and 4 measure nutrition and hydration status but are not associated with effectiveness of the weight loss program.