Nokea
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
- A. Osmolarity
- B. Glucose
- C. Albumin
- D. Platelets
Correct Answer: B
Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.
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What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
- A. Hypertonia and dark skin
- B. Low-set ears and a simian crease
- C. Inner epicanthal folds and a high, domed forehead
- D. Long, thin fingers and excessive hair
Correct Answer: B
Rationale: The correct answer is B: 'Low-set ears and a simian crease.' These are key physical characteristics commonly seen in newborns with Down syndrome. Low-set ears, along with a simian crease (a single palmar crease), are indicative of Down syndrome. Choices A, C, and D are incorrect because hypertonia, dark skin, inner epicanthal folds, a high, domed forehead, long, thin fingers, and excessive hair are not specific features associated with Down syndrome in newborns. Therefore, the presence of low-set ears and a simian crease should raise suspicion for Down syndrome and prompt further evaluation.
Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?
- A. Compare the client's pain scale rating with the prescribed dosing.
- B. Determine which prescription will have the quickest onset of action.
- C. Ask the client to choose which medication is needed for the pain.
- D. Document the client's report of pain in the electronic medical record.
Correct Answer: A
Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client's pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.
The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
- A. Inflammation of the vessels
- B. Obstructed blood flow
- C. Overhydration
- D. Stress-related headaches
Correct Answer: B
Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
- A. Review the client's dietary intake of high protein foods
- B. Notify the healthcare provider of the finding immediately
- C. Discuss approaches to chronic pain control with the client
- D. Assess the client's radial pulses and capillary refill time
Correct Answer: C
Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.
What is the hallmark sign of intussusception?
- A. Mucus-like stools
- B. Currant jelly-like stools
- C. Tarry, black stools
- D. Green, soft stools
Correct Answer: B
Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.