Nokea
A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating?
- A. That the client is not adapting well to the disability
- B. That the problem is likely to get worse before it gets better
- C. That the client is experiencing the usual sequelae of a stroke
- D. That the client is experiencing the side effects of prescribed anticoagulants
Correct Answer: C
Rationale: After a thrombotic stroke, the client often experiences periods of emotional lability, which are characterized by sudden bouts of laughing or crying or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture of the client with this health problem, although it may be difficult for health care personnel and family members to deal with it. The other options are incorrect.
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At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?
- A. The fetal heart rate slowly drops to 110 beats/min during strong contractions, recovering to 138 beats/min immediately afterward.
- B. Fresh meconium is found on the examiner's gloved fingers after a vaginal exam, and the fetal monitor pattern remains essentially unchanged.
- C. Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline.
- D. The vaginal exam continues to reveal some old meconium staining, and the fetal monitor demonstrates a U-shaped pattern of deceleration during contractions, recovering to a baseline of 140 beats/min.
Correct Answer: C
Rationale: Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function that is frequently noted with a fetus of more than 38 weeks' gestation. Fresh meconium, in combination with late decelerations and a variable descending baseline, is an ominous signal of fetal distress caused by fetal hypoxia. It is not unusual for the fetal heart rate to drop to less than the 140 to 160 beats/min range in late labor during contractions, and, in a healthy fetus, the fetal heart rate will recover between contractions. Old meconium staining may be the result of a prenatal trauma that is resolved.
A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?
- A. If I feel dizzy, I'll skip my dose for a few days.
- B. I can't see the numbers on the label to know how much salt is in the food.
- C. I understand why I have to keep taking the pills even when my blood pressure is normal.
- D. If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor.
Correct Answer: A
Rationale: Prazosin is used to treat hypertension. The side effects of prazosin are dizziness and impotence. The client needs to be instructed to call the primary health care provider if these side effects occur. Holding (skipping) medication will cause an abrupt rise in blood pressure. Option 2 indicates difficulty taking care of oneself. The remaining options indicate client understanding regarding the medication.
A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.
A 3-week-old infant is brought to the well-baby clinic for a phenylketonuria (PKU) screening test. The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL (60 mmol/L). What is the nurse's priority action?
- A. Report the test as inconclusive.
- B. Tell the mother that the test is normal.
- C. Prepare to perform another test on the client.
- D. Notify the pediatrician that the test is moderately elevated.
Correct Answer: A
Rationale: The normal PKU level is 0.8 to 1.8 mg/dL (48 to 109 mmol/L). With early postpartum discharge, screening is often performed when the infant is less than 2 days old because of the concern that the infant will be lost to follow-up. Infants should be rescreened by the time that they are 14 days old if the initial screening was done when the infant was 24 to 48 hours old.
A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?
- A. An elevated platelet count
- B. Elevated hemoglobin and hematocrit levels
- C. Bone marrow exam showing increased megakaryocytes
- D. Bone marrow exam indicating increased immature white blood cells
Correct Answer: C
Rationale: The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 mm^3 (20 × 10^9/L). Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the precursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia.