Nokea
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.
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The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: Furosemide IV is a diuretic medication commonly used to treat conditions such as pulmonary edema. In the case of pulmonary edema, the excess fluid accumulates in the lungs, leading to symptoms such as difficulty breathing, wheezing, and the production of pink, frothy sputum. The presence of pink, frothy sputum is a classic sign of pulmonary edema and indicates the presence of fluid in the airways. Therefore, the nurse would evaluate the effectiveness of furosemide IV treatment by monitoring the resolution of this specific symptom, as it indicates improvement in the underlying condition of pulmonary edema.
.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
- A. It will help him overcome urinary incontinence
- B. It will promote renal blood flow and flush bacteria from the urinary tract
- C. It will help him eliminate urinary odors
- D. It will provide relief from pain and discomfort as a result of urinary tract infection DISTURBANCES IN FLUIDS AND ELECTROLYTES
Correct Answer: B
Rationale: The client is advised to drink 2-3 liters of water daily because it will promote renal blood flow and flush bacteria from the urinary tract. Increased water intake helps to dilute the urine, making it easier to flush out harmful bacteria that may be causing the urinary discomfort and urethritis. Adequate hydration is crucial for maintaining healthy urinary function and preventing urinary tract infections. By increasing water consumption, the client can help reduce the concentration of bacteria in the urinary tract, supporting the effectiveness of the prescribed antibiotics in treating the urethritis.
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- A. Wash the radiation site vigorously with soap and water to remove dead cells.
- B. Eat a diet high in protein and calories to optimize tissue repair.
- C. Apply coo! compresses to the radiation site to reduce edema,
- D. Drink warm fluids throughout the day to relieve discomfort in swallowing
Correct Answer: B
Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.
A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following?
- A. 25 g/day, initially
- B. Delayed until after thyroid surgery
- C. 100 g/day, initially
- D. Initiated before thyroid surgery
Correct Answer: A
Rationale: In a client with a history of two myocardial infarctions and coronary artery disease, initiating levothyroxine therapy with a low starting dose of 25 mcg/day is recommended. Thyroid hormone replacement therapy can potentially worsen underlying cardiac conditions, so a cautious approach is necessary. The dose may be gradually titrated upwards based on thyroid function tests and the client's response. Delaying treatment until after thyroid surgery (option B) is not necessary in this scenario if the client requires thyroid hormone replacement. Initiating levothyroxine before thyroid surgery (option D) is not relevant to the given clinical situation. Starting with a higher dose of 100 mcg/day (option C) may pose a higher risk of cardiac complications in this client with a cardiac history.
A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the nurse implement?
- A. Provide stimulation during feeding.
- B. Avoid being persistent during feeding time.
- C. Limit feeding time to 10 minutes.
- D. Maintain a face-to-face posture with the infant during feeding.
Correct Answer: A
Rationale: Providing stimulation during feeding is the most appropriate intervention for a 12-month-old infant with failure to thrive. Infants with failure to thrive may have decreased interest in feeding or difficulty with obtaining adequate nutrition. By providing stimulation during feeding, such as making eye contact, talking gently, and playing soft music, the nurse can help increase the infant's interest and engagement in feeding. This can lead to improved feeding outcomes and help the infant receive the necessary nutrition for growth and development.