Nokea
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated sed rate
- D. Increased glucose
Correct Answer: A
Rationale: High protein levels in the cerebrospinal fluid are indicative of bacterial meningitis, as the presence of bacteria in the CSF leads to increased protein production. Elevated protein levels can be seen in inflammatory conditions like meningitis. Choice B, clear color, is not expected in meningitis as it is typically associated with cloudy or turbid CSF. Elevated sed rate (choice C) and increased glucose (choice D) are not typically associated with the laboratory findings seen in meningitis.
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The family presents several problems. Which of the following criteria is considered in determining the priority health problem?
- A. expected consequence of the problem
- B. cooperation and support of the family
- C. involvement of the family members in the problem
- D. modifiability of the problem
Correct Answer: D
Rationale: When determining the priority health problem within a family, one key criterion to consider is the modifiability of the problem. This means assessing whether the health issue can be changed or improved through interventions. Choices A, B, and C are not directly related to the priority of the health problem within the family. The expected consequence of the problem, cooperation and support of the family, and involvement of family members are important factors but do not specifically address the priority of the health issue based on modifiability.
The nurse is caring for an acutely ill 10-year-old client. Which of the following assessments would require the nurse's immediate attention?
- A. Rapid bounding pulse
- B. Temperature of 38.5 degrees Celsius
- C. Profuse diaphoresis
- D. Slow, irregular respirations
Correct Answer: D
Rationale: The correct answer is D, slow, irregular respirations. In an acutely ill child, this assessment can indicate impending respiratory failure or neurological compromise, necessitating immediate intervention. Rapid bounding pulse (choice A) may indicate tachycardia but is not as immediately concerning as compromised respirations. A temperature of 38.5 degrees Celsius (choice B) is elevated but may not be the most urgent concern unless accompanied by other symptoms. Profuse diaphoresis (choice C) can indicate increased sympathetic activity but is not as critical as respiratory compromise.
The nurse is preparing an orientation class for new employees at an inner city clinic that serves a low-income population. Which information should the nurse include in the presentation to these new employees?
- A. A lack of transportation is a major barrier for the clinic's clients.
- B. Basic physiologic needs are likely to be unmet in this clinic's client population.
- C. Printed material is less effective for this population with limited reading skills.
- D. Group education classes are often poorly attended by non-compliant clients.
Correct Answer: B
Rationale: The correct answer is B because addressing basic physiologic needs is crucial for low-income populations. Ensuring that basic needs such as food, shelter, and safety are met is essential for these clients to engage effectively in their healthcare. Choice A talks about transportation, which can be a barrier but may not be the major impediment. Choice C focuses on printed material and reading skills, which are important but not as fundamental as addressing basic physiologic needs. Choice D makes assumptions about client attendance based on compliance, which is not the most critical information to include in an orientation about serving a low-income population.
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: The client's inability to effectively clear the airway due to pain and sputum production hinders the cough mechanism, making 'Ineffective airway clearance' the most appropriate nursing diagnosis. Although impaired gas exchange may occur due to the pneumonia, the immediate issue is the inability to clear the airway. 'Ineffective breathing pattern' does not address the specific issue of airway clearance. 'Anxiety' is not the priority when the focus should be on the physical complications of pneumonia.
What title should be given to this occupational health nurse job description?
- A. manager
- B. case manager
- C. health educator
- D. nurse consultant
Correct Answer: D
Rationale: The correct title for this occupational health nurse job description is 'nurse consultant.' A nurse consultant is a registered professional nurse with expertise in occupational and environmental health nursing, effective communication skills, and good administrative and consultative abilities. Choice A, 'manager,' is incorrect as the job description does not primarily focus on managerial duties. Choice B, 'case manager,' is incorrect as it does not fully cover the scope of the described role. Choice C, 'health educator,' is incorrect as it does not encompass the administrative and consultative skills mentioned in the job description.