Nokea
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity based on lab and clinical findings (e.g., age, white blood cell count, glucose). Vital signs (B) and urine output (C) are important but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis.
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A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?
- A. Include family members in preoperative teaching sessions.
- B. Encourage the client to ask questions about managing an ileostomy.
- C. Provide a brief, thorough explanation of all preoperative and postoperative procedures.
- D. Invite a member of the ostomy association to visit the client.
Correct Answer: B
Rationale: Encouraging the client to ask questions about managing an ileostomy promotes active engagement, addresses specific concerns, and supports psychological preparation. Including family, providing explanations, or arranging visits are helpful but less directly empower the client's coping process. CN: Psychosocial adaptation; CL: Synthesize
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client's vital signs
- B. Administer a bolus of lactated Ringer's solution
- C. Assess the client's neurologic status
- D. Contact the physician
Correct Answer: A
Rationale: Sharp midchest pain in a client with a thoracic aneurysm suggests possible dissection or rupture, a life-threatening emergency. Assessing vital signs (e.g., hypotension, tachycardia) first provides critical data to guide action. Fluid bolus, neurologic assessment, or contacting the physician follow based on findings.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.