Nokea
A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.
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The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care?
- A. Mild soap
- B. Oil in the bath water
- C. Lanolin-based lotion
- D. Alcohol cleansing pads
Correct Answer: D
Rationale: Alcohol cleansing pads increase skin dryness and pruritus in chronic kidney disease clients with uremia. Mild soap, bath oils, and lanolin-based lotions help reduce dryness and irritation without exacerbating symptoms.
A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken?
- A. Alprazolam
- B. Warfarin sodium
- C. Potassium chloride
- D. Verapamil hydrochloride
Correct Answer: C
Rationale: Spironolactone is a potassium-retaining diuretic. If the client is also taking potassium chloride or another potassium supplement, the risk for hyperkalemia exists. Potassium doses need to be adjusted while the client is taking this medication. A dosage adjustment would not be necessary if the client was taking alprazolam, warfarin sodium, or verapamil hydrochloride.
A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?
- A. I will report a fever or sore throat to my doctor.
- B. Some joint pain is expected and is nothing to worry about.
- C. I must brush my teeth frequently to avoid damage to my gums.
- D. My urine may turn red in color, but this is nothing to be concerned about.
Correct Answer: A
Rationale: Carbamazepine is an anticonvulsant medication and is also used to alleviate the pain associated with trigeminal neuralgia. Agranulocytosis is an adverse effect of carbamazepine, and it places the client at risk for infection. If the client develops a fever or a sore throat, the primary health care provider should be notified. Unusual bruising and bleeding are also adverse effects of the medication, and they need to be reported to the primary health care provider if they occur.
A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is performed because of the child's exposure to HIV infection. Which home care instruction should the nurse provide to the parents of the child?
- A. Avoid sharing toothbrushes.
- B. Avoid all immunizations until the diagnosis is established.
- C. Wipe up any blood spills with a rag, and allow them to air-dry.
- D. Wash your hands with half-strength bleach if they come in contact with the child's blood.
Correct Answer: A
Rationale: Parents should avoid sharing toothbrushes to prevent potential HIV transmission through blood or bodily fluids. Immunizations should be kept up to date to protect the child. Blood spills should be cleaned with a paper towel, followed by soap and water, then a bleach solution, not just a rag and air-drying. Washing hands with soap and water is sufficient; bleach is too caustic for skin.
What factors should the nurse consider for teaching a child about his or her disease and related health care measures?
- A. A child rarely forms misconceptions.
- B. The older the child, the shorter the attention span.
- C. A child's imagination may create greater fear than the truth.
- D. A child may regress developmentally in a situation of illness.
- E. It is not necessary to assess the child's knowledge before teaching.
- F. A child may better manage uncomfortable information through role-playing.
Correct Answer: C,D,F
Rationale: For children, the teaching-learning process may be fundamentally different from that used for adults, and the nurse needs to adjust the complexity and volume of information based on the child's age and cognitive level. The factors that need to be addressed when teaching children include the following: Trust is essential to a therapeutic relationship; in general, the younger the child, the shorter the attention span; assessing the child's knowledge is important because children are exposed to various levels of information about health care; children form misconceptions easily, and a child's imagination may create greater fear than the truth; a child may regress developmentally in a situation of illness; and a child may better manage uncomfortable information through role-playing.