Nokea
A client is diagnosed with diabetes insipidus. The nurse should plan interventions to address which manifestations of this disorder? Select all that apply.
- A. Bradycardia
- B. Hypertension
- C. Poor skin turgor
- D. Increased urinary output
- E. Dry mucous membranes
- F. Decreased pulse pressure
Correct Answer: C,D,E,F
Rationale: Diabetes insipidus is a water metabolism problem caused by an antidiuretic hormone (ADH) deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH). Clinical manifestations include poor skin turgor, increased urinary output, dry mucous membranes, decreased pulse pressure, tachycardia, hypotension, weak peripheral pulses, and increased thirst.
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The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites?
- A. Loose but intact pin sites
- B. Clear drainage from the pin sites
- C. Purulent drainage from the pin sites
- D. Redness and swelling around the pin sites
Correct Answer: B
Rationale: A small amount of clear drainage ('weeping') may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
- A. Checking for a rash on the digits
- B. Observing for softening of the nails or nail beds
- C. Palpating for a rapid or irregular peripheral pulse
- D. Palpating for diminished or absent peripheral pulses
Correct Answer: D
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
- A. Takes blood pressures in the right arm only
- B. Draws serum laboratory samples from the right arm only
- C. Positions the client supine and flat with the right arm elevated on a pillow
- D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D
Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.