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A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Increased urine osmolarity
- C. Distended neck veins
- D. serum sodium level
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
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A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: In a client with end-stage acquired immunodeficiency syndrome (AIDS) manifesting with profound Cryptosporidium infection, fluid replacement is crucial for managing the symptoms and complications. Cryptosporidium infection can cause severe diarrhea and dehydration, leading to significant fluid loss. Therefore, the primary focus of care in this situation should be on maintaining adequate hydration through fluid replacement. This is essential for preventing further complications and supporting the client's overall health and well-being. Pain management, antiretroviral therapy, and high-calorie intake may be important aspects of care in other situations but are not the priority in managing a client with severe Cryptosporidium infection and dehydration.
The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that:
- A. soft and flexible shoes are generally better.
- B. high-top shoes are necessary for support.
- C. inflexible shoes are necessary to prevent in-toeing and out-toeing.
- D. this type of shoe will encourage the infant to walk sooner.
Correct Answer: A
Rationale: Soft and flexible shoes are generally better for infants who are learning to walk. Infants have soft and pliable bones in their feet that are still developing, so it is important for them to wear shoes that allow natural movement and flexibility. High-top shoes and inflexible shoes may restrict the natural movement of the foot and can hinder the infant's ability to develop balance and coordination while learning to walk. It is important for infants to wear shoes that are comfortable, lightweight, and provide some protection without restricting their foot movements.
Hepatitis C virus infection is a risk factor for which of the following malignancy?
- A. hepatoblastoma
- B. splenic lymphoma
- C. Hodgkin lymphoma
- D. nasopharyngeal carcinoma
Correct Answer: B
Rationale: Hepatitis C is a known risk factor for splenic lymphoma and other B-cell lymphoproliferative disorders.
The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition?
- A. Oliguria and hypertension
- B. Hematuria and pallor
- C. Proteinuria and muscle cramps
- D. Bacteriuria and facial edema
Correct Answer: A
Rationale: Acute renal failure is characterized by a sudden decrease in kidney function, resulting in the reduced ability to excrete waste products and maintain fluid balance. The primary clinical manifestations typically seen in acute renal failure include oliguria (low urine output) due to decreased kidney function, and hypertension (high blood pressure) as the body retains excess fluid and waste products. These symptoms indicate impaired kidney function and the need for immediate medical intervention to prevent further complications. Hematuria, proteinuria, muscle cramps, bacteriuria, and facial edema are not typically primary clinical manifestations of acute renal failure.
The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
- A. achieves a weight of at least 3 pounds.
- B. indicates an interest in breastfeeding.
- C. does not require supplemental oxygen.
- D. has adequate sucking and swallowing reflexes.
Correct Answer: D
Rationale: Breastfeeding can be initiated when the newborn has adequate sucking and swallowing reflexes, which usually develop around 34 to 36 weeks gestational age. It is important for the newborn to have the ability to latch onto the breast and suck effectively in order to receive adequate nutrition and establish a good breastfeeding relationship with the mother. Indicating an interest in breastfeeding is important as well, but having the reflexes necessary for successful breastfeeding is a key factor in determining readiness to begin breastfeeding.