Nokea
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?
- A. Pain related to joint inflammation
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Disturbed sleep pattern.
Correct Answer: A
Rationale: Pain is the most immediate and distressing symptom for the client and should be addressed first to improve comfort and quality of life.
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A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?
- A. Determine if the client is using an inhaler before exercising
- B. Advise the client to avoid all physical activity
- C. Encourage the client to increase fluid intake before exercise
- D. Recommend the client wear a mask while exercising
Correct Answer: A
Rationale: Using an inhaler before exercise can help manage asthma symptoms by preventing bronchoconstriction during physical activity.
The following syndromes are caused by chromosomal abnormalities:
- A. Cri-du-chat syndrome
- B. Kearns-Sayre syndrome
- C. Marfan's syndrome
- D. Turner's syndrome
Correct Answer: D
Rationale: Turner's syndrome: Turner's syndrome is caused by a monosomy of the X chromosome, characterized by short stature, infertility, and heart defects.
Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
- A. Neurogenic
- B. Cardiogenic
- C. Hypovolemic
- D. Anaphylactic
Correct Answer: D
Rationale: Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.
The nurse is assessing a child with acute otitis media. Which finding should the nurse expect?
- A. Bilateral eye discharge and fever
- B. A bulging, red tympanic membrane
- C. Nasal congestion and headache
- D. Persistent cough and sore throat
Correct Answer: B
Rationale: Acute otitis media typically presents with a bulging, red tympanic membrane due to fluid accumulation and infection.
What are TWO possible interventions for an infant with Tetralogy of Fallot who has recurrent desaturation episodes on propranolol?
- A. Full surgical repair
- B. Interim repair with RVOT stent or shunt
- C. Propranolol dose adjustment
- D. All of the above
Correct Answer: B
Rationale: Interim repair with RVOT stent or shunt can be used to improve oxygenation in infants who are not candidates for immediate full surgical repair.