Nokea
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
- A. Providing activities of daily living on the time schedule that the client wishes.
- B. Offering foods that the client enjoys in order to increase the intake of calories.
- C. Decreasing cardiac demands by promoting rest.
- D. Listening to concerns about the hospitalization.
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.
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After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?
- A. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange.
- B. Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery.
- C. Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated.
- D. Deep breathing expands the alveoli and increases the lung surface available for ventilation.
Correct Answer: D
Rationale: Deep breathing expands alveoli, increasing lung surface for ventilation and preventing atelectasis post-thoracotomy. It does not elevate the diaphragm, increase blood flow, or control airflow to prevent hyperinflation.
The nurse develops a teaching plan for a client scheduled for a spinal fusion. Which of the following should the nurse expect to include?
- A. The client typically experiences more pain at the donor site than at the fusion site.
- B. The surgeon will apply a simple gauze dressing to the donor site.
- C. Neurovascular checks are unnecessary if the fibula is the donor site.
- D. The client's level of activity restriction is determined by the amount of pain.
Correct Answer: A
Rationale: The donor site (e.g., iliac crest) often causes more pain than the fusion site due to tissue trauma.
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
- A. Respiratory rate greater than 16 breaths/minute.
- B. Continuous bubbling in the water-seal chamber.
- C. Fluid in the chest tube.
- D. Fluctuation of fluid in the water-seal chamber.
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring physician notification. A respiratory rate >16 is normal. Fluid in the tube and fluctuation are expected.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
Ergotamine tartrate (Gynergen) is prescribed for a client's migraine headaches. The client's report of which of the following indicates effectiveness?
- A. Prevention of the migraine.
- B. Reduced severity of the developing migraine.
- C. Relief from the sleeplessness experienced in the past after a migraine.
- D. Relief from the vision problems experienced in the past after a migraine.
Correct Answer: B
Rationale: Ergotamine reduces the severity of developing migraines by constricting cranial blood vessels. It is not primarily preventive or used for post-migraine sleeplessness or vision issues.