Nokea
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
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A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
- A. Enlarged, painless lymph nodes.
- B. Headache.
- C. Hyperplasia of the gums.
- D. Unintentional weight loss.
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
The following scenario applies to the next 1 items
The emergency department nurse cares for a child with otitis media
Item 1 of 1
Nurses' Note
Vital Signs
Orders
1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
- A. ventrogluteal
- B. dorsogluteal
- C. Abdomen
- D. nerve damage.
- E. staining of the skin
- F. hydrocortisone
- G. EMLA (lidocaine and prilocaine)
Correct Answer: A,D,G
Rationale: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels in hepatic encephalopathy. Coordination (C) and pupil reaction (D) are less relevant. High carbohydrates (E) are not specific, and physical activity (F) may be limited.