Nokea
A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become
- A. darker and more pigmented.
- B. ruddy and oily.
- C. puffy and scaly.
- D. pale and dry.
Correct Answer: A
Rationale: increase in melanocyte-stimulating hormone results in 'eternal tan'
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A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
- A. Observe the client for grimaces, flinching, and other signs of pain.
- B. Monitor the client's blood pressure.
- C. Ask the client to rate his pain on a scale of 1 to 10.
- D. Monitor the client's pulse and respirations.
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
- A. Surfing
- B. Scuba diving
- C. Parasailing
- D. Swimming
Correct Answer: B
Rationale: Scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumbar puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made?
- A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm³.
- B. CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm³.
- C. CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm³.
- D. CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm³.
Correct Answer: A
Rationale: CSF normally clear, colorless; normal WBC 5,000-10,000 per cubic millimeter, normal Hgb (male 13.5-17.5 g/dL, female 12-16 g/dL), normal Hct (male 41-53%, female 36-46%)
A client is diagnosed with lung cancer and undergoes a pneumonectomy.
In the immediate postoperative period, which of the following nursing assessments is MOST important?
- A. Presence of breath sounds bilaterally.
- B. Position of the trachea in the sternal notch.
- C. Amount and consistency of sputum.
- D. Increase in the pulse pressure.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation