Nokea
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
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When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
- A. A reduced white blood cell count
- B. A decreased platelet count
- C. Shallow respirations
- D. Tachypnea
Correct Answer: D
Rationale: Tachypnea is a compensatory mechanism in metabolic acidosis to help expel excess carbon dioxide and correct the acid-base imbalance.
All the following statements about spontaneous coronary artery dissection are true, except
- A. More common in young females
- B. Proximal coronary involvement associated with immuno-inflammatory disease
- C. Intra-coronary imaging shows 'accordion sign'
- D. Physical stress precipitates it by causing intimal tear
Correct Answer: C
Rationale: The 'accordion sign' is not typically associated with spontaneous coronary artery dissection.
A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?
- A. Thrombus formation
- B. Infection
- C. Bronchospasm
- D. Heart failure
Correct Answer: A
Rationale: After a cardiac catheterization, the nurse must monitor for thrombus formation as it is a common complication in the first 24 hours.
Corneal opacities are seen in:
- A. Marfan's syndrome
- B. Herpes simplex infection
- C. Hurler syndrome
- D. Osteogenesis imperfecta
Correct Answer: C
Rationale: Corneal opacities are a characteristic feature of Hurler syndrome, a type of mucopolysaccharidosis.
All of the following immune-mediated diseases are associated with antineutrophil cytoplasmic antibody, except
- A. Wegener granulomatosis
- B. Churg-Strauss syndrome
- C. Microscopic polyangiitis
- D. Henoch-Schönlein purpura
Correct Answer: D
Rationale: Henoch-Schönlein purpura is not associated with antineutrophil cytoplasmic antibodies (ANCA); it is an IgA-mediated vasculitis.