Nokea
A client with a history of pancreatitis is admitted with abdominal pain. The nurse should expect which of the following laboratory findings?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in pancreatitis due to pancreatic enzyme release.
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Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?
- A. Deficient knowledge
- B. Risk for injury
- C. Situational low self-esteem
- D. Acute pain
Correct Answer: B
Rationale: Risk for injury is a priority nursing diagnosis for a child with hemophilia due to the risk of bleeding from minor trauma. Other diagnoses may apply but are less critical long-term.
When a child is able to grasp the idea that a ball continues to exist even though his parent placed the ball under a hat, the child is in which of the following stages in the development of logical thinking, according to Piaget?
- A. Sensorimotor.
- B. Preoperational.
- C. Concrete operations.
- D. Formal operations.
Correct Answer: A
Rationale: Object permanence, understanding that objects exist when out of sight, develops during the sensorimotor stage (birth to 2 years) per Piaget's theory.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this 'gate' to pain are low endorphins and anxiety and that some of the factors that close this 'gate' to pain are decreased anxiety and fear?
- A. Moritz Schiff's theory of pain
- B. The Intensive Theory of Pain
- C. Melzack and Wall's theory of pain
- D. The Specificity Theory of Pain
Correct Answer: C
Rationale: Melzack and Wall's Gate Control Theory posits that pain perception is modulated by factors like anxiety (opening the gate) and reduced anxiety or endorphins (closing the gate).
A client with a moderate level of anxiety is pacing quickly in the hall. As the nurse approaches, he states, 'Help me. I can't take it anymore.' Which of the following would be the best response initially?
- A. It would be best if you would lie down until you're calmer.'
- B. Let's go to a quieter area where we can talk if you want.'
- C. Try doing your relaxation exercises to calm down.'
- D. I'll get some medicine to help you relax.'
Correct Answer: B
Rationale: Offering to talk in a quieter area de-escalates anxiety and provides a supportive environment.