Nokea
A client with AIDS is admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and disorientation pose a risk for injury, such as pulling out the IV or falling, making this the priority nursing diagnosis.
You may also like to solve these questions
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.
A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
- A. Placing a note in the chart for the doctor
- B. Rechecking the temperature in 4 hours
- C. Notifying the physician immediately
- D. Asking the client if he has been feeling sick
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A. Avoid a high-fiber diet
- B. Continue to use ice packs
- C. Take a laxative daily to prevent constipation
- D. Use a sitz bath after each bowel movement
Correct Answer: D
Rationale: A sitz bath promotes healing and relieves pain after a hemorrhoidectomy by keeping the area clean and reducing inflammation.
The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?
- A. Frothy vaginal discharge
- B. Thick, white vaginal discharge
- C. Purulent vaginal discharge
- D. Watery vaginal discharge
Correct Answer: D
Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which may manifest as watery or blood-tinged vaginal discharge. Frothy, thick white, or purulent discharges are more indicative of infections or other gynecologic conditions.
A patient with hypothyroidism states that she takes Synthroid® 0.112 mg daily, but the pharmacy has issued the drug labeled in micrograms. How many micrograms of Synthroid® is equivalent to 0.112 mg? Record your answer using a whole number.
Correct Answer: 112
Rationale: To convert milligrams to micrograms, multiply by 1,000: 0.112 mg X 1,000 = 112 micrograms.