Nokea
A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statement by the client would be most indicative of the etiology of this crisis?
- A. I knew this would happen. I've been eating too much red meat lately.
- B. I really enjoyed my fishing trip yesterday. I caught 2 fish.
- C. I have really been working hard practicing with the debate team at school.
- D. I went to the healthcare provider last week for a cold, and I have gotten worse.
Correct Answer: D
Rationale: The correct answer is D because a recent illness, such as a cold, can trigger a vaso-occlusive crisis in sickle cell disease. This crisis is often precipitated by infections or other illnesses that cause a systemic inflammatory response, leading to vaso-occlusion. Choices A, B, and C do not directly relate to the etiology of a vaso-occlusive crisis in sickle cell disease, making them incorrect.
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A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?
- A. Check the protein level in urine
- B. Have the client turn to the left side
- C. Take the temperature
- D. Monitor the urine output
Correct Answer: B
Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.
A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 90 beats per minute
- B. A blood pressure of 120/80 mm Hg
- C. A respiratory rate of 16 breaths per minute
- D. A temperature of 98.6 degrees Fahrenheit
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.
A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?
- A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles are usually left in for 15 to 30 minutes.
- B. In traditional Chinese medicine, imbalances in the basic energetic flow of life - known as qi or chi - are thought to cause illness.
- C. The flow of life is believed to flow through major pathways in your body rather than nerve clusters.
- D. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.
Correct Answer: C
Rationale: The belief stated in option C is incorrect about acupuncture. Acupuncture is based on the concept of qi flowing through major pathways in the body, known as meridians, rather than nerve clusters. This traditional Chinese medicine practice aims to balance the flow of qi to promote health and healing. Options A, B, and D are consistent with the principles of acupuncture and are not incorrect beliefs. Option A describes the depth and duration of needle placement, option B explains the role of imbalances in qi flow causing illness, and option D outlines how acupuncture helps rebalance energy flow for the body's natural healing mechanisms.
A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct Answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.
When another nurse enters the room in response to a call, after checking the client's pulse and respirations during CPR on an adult in cardiopulmonary arrest, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: The correct answer is to participate in compressions or breathing. This is essential to ensure continuous and effective CPR. Relieving the nurse performing CPR (Choice A) is not recommended as it can interrupt the life-saving procedure. Going to get the code cart (Choice B) may be necessary in certain situations but should not take precedence over providing immediate assistance in CPR. Validating the client's advanced directive (Choice D) is not the primary role in this scenario where urgent action is needed to support the client's circulation and breathing.