Nokea
A client post-hemodialysis reports dizziness. The nurse should:
- A. Check blood pressure.
- B. Administer fluids.
- C. Encourage eating.
- D. Increase dialysis time.
Correct Answer: A
Rationale: Dizziness may indicate hypotension, a common post-dialysis issue.
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A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
- A. Report hematuria to the physician.
- B. Strain the urine carefully.
- C. Administer meperidine (Demerol) every 3 hours.
- D. Apply warm compresses to the flank area.
Correct Answer: B
Rationale: Straining urine is critical when pain becomes intermittent, indicating possible stone passage, to confirm stone expulsion and guide treatment.
Signs and symptoms of Cushing's disease include:
- A. Weight loss.
- B. Thin, fragile skin.
- C. Hypotension.
- D. Abdominal pain.
Correct Answer: B
Rationale: Thin, fragile skin is a hallmark of Cushing's disease due to cortisol's catabolic effects on connective tissue.
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
- A. Apply sunscreen only after going into the water.
- B. Avoid peak exposure hours from 9 a.m. to 1 p.m.
- C. Wear loosely woven clothing for added ventilation.
- D. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
Correct Answer: D
Rationale: Applying sunscreen with SPF 15 or higher before sun exposure is a key measure to prevent UV damage. Sunscreen should be applied before water exposure, peak hours are 10 a.m. to 4 p.m., and tightly woven clothing is better for protection.