Nokea
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
- A. Encourage the client to drink at least 1,000 mL per day.
- B. Provide parenteral rehydration therapy ordered by the physician.
- C. Turn and reposition every 2 hours.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize
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A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
- A. Increase the amount of iron in the client's diet.
- B. Apply lotion to the lower extremities.
- C. Elevate the legs.
- D. Consult the oncologist.
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
Which of the following has been identified as a potential risk factor for the development of colon cancer?
- A. Chronic constipation.
- B. Long-term use of laxatives.
- C. History of smoking.
- D. History of inflammatory bowel disease.
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze
A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for which of the following?
- A. Tachycardia.
- B. Bradycardia.
- C. Decreased urine output.
- D. Hypotension.
Correct Answer: A
Rationale: Hemorrhage in a client with thrombocytopenia can lead to hypovolemia, causing tachycardia as the heart compensates for decreased blood volume. Bradycardia is not typical, and while decreased urine output and hypotension may occur later, tachycardia is an earlier and more immediate sign.
Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication?
- A. Increase the amount of potassium in the diet.
- B. Maintain a regular program of weight-bearing exercise.
- C. Limit dietary vitamin D intake.
- D. Perform isometric exercises.
Correct Answer: B
Rationale: Weight-bearing exercise promotes bone density, counteracting bone resorption caused by excess cortisol in Cushing's disease.