Nokea
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
- A. The blood pressure
- B. The temperature
- C. The urinary output
- D. The specific gravity of the urine
Correct Answer: A
Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.
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A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
- A. Accepting her present body image
- B. Verbalizing realistic feelings about her body
- C. Having an improved perception of her body image
- D. Exhibiting increased self-esteem
Correct Answer: B
Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
- A. Pain related to tissue damage from burns
- B. Potential for infection related to contamination of wounds
- C. Fluid volume deficit related to increased capillary permeability
- D. Potential for impaired gas exchange related to edema of respiratory tract
Correct Answer: D
Rationale: (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. I know it was my fault that it happened, because I shouldn't have been out so late.'
- B. If I had not worn that sexy dress that night, he wouldn't have raped me.'
- C. I know my date just had so much passion he couldn't handle me saying 'no.'
- D. I know now that it was not my fault, but I want to continue counseling after my discharge.'
Correct Answer: D
Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.
A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods.
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw foods like tossed salad (A) can harbor pathogens, risky for AIDS patients with diarrhea. Baked chicken (B), broiled fish (C), and steamed rice (D) are cooked and safer, indicating further teaching is needed for A.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.