Nokea
A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.
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The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.
A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. "Tell me about his pain."?
- B. "What does his vomit look like?"?
- C. "Describe his usual diet."?
- D. "Have you noticed changes in his abdominal size?"?
Correct Answer: C
Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
- A. A client with Alzheimer's disease
- B. A client with pneumonia
- C. A client with appendicitis
- D. A client with thrombophlebitis
Correct Answer: A
Rationale: The client with Alzheimer's disease is the most stable among the clients listed and can be appropriately assigned to the nursing assistant. Nursing assistants are capable of providing care such as feeding and assisting with activities of daily living for individuals with Alzheimer's disease. Clients with pneumonia, appendicitis, and thrombophlebitis are less stable and necessitate the expertise of a registered nurse for accurate assessment and interventions. Therefore, the nursing assistant can effectively care for the client with Alzheimer's disease while ensuring that the other clients receive the necessary level of care from a registered nurse.
The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:
- A. Nasal congestion
- B. Abdominal tenderness
- C. Muscle tetany
- D. Oliguria
Correct Answer: A
Rationale: During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.
When discussing the patterns of use of alcohol and other drugs, which piece of information should the nurse include?
- A. Lifetime prevalence and intensity of alcohol use are greater in men than in women.
- B. Caucasians report higher levels of alcohol use than African Americans or Hispanics.
- C. Overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age.
- D. Heavy use is more common in lower socioeconomic groups due to affordability.
Correct Answer: C
Rationale: The correct answer is that overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age. Recent research indicates that alcohol and illicit drug use tends to rise into the mid-20s and then decline with age. Choices A and B are incorrect because lifetime prevalence and intensity of alcohol use are greater in men than in women, and Caucasians do not report higher levels of alcohol use compared to African Americans or Hispanics. Choice D is incorrect because heavy use is more common in lower socioeconomic groups due to factors like stress, coping mechanisms, and availability, not just affordability.