Nokea
A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
- A. Lie supine with his neck extended
- B. Sit upright, leaning slightly forward
- C. Blow his nose and then put lateral pressure on his nose
- D. Hold his nose while bending forward at the waist
Correct Answer: B
Rationale: The nurse should instruct the client to sit upright, leaning slightly forward when experiencing epistaxis (nosebleed). This position helps prevent blood from dripping down the back of the throat, reducing the risk of aspiration. In the case of a client with thrombocytopenia secondary to leukemia, the blood may have difficulty clotting due to low platelet counts. Therefore, it is important to minimize bleeding as much as possible. Lying supine with the neck extended may increase the risk of blood flowing down the throat, while blowing the nose or putting lateral pressure on it may aggravate the bleeding. Holding the nose while bending forward at the waist may also increase blood flow towards the head. Sitting upright, leaning slightly forward is the safest position to prevent complications associated with epistaxis in this case.
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A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
- A. Deficient fluid volume related to osmotic diuresis
- B. Decreased cardiac output related to increased heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The most appropriate position for a patient with right-sided paralysis following a stroke is Option B - On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?
- A. It estimates a child's level of pain utilizing vital sign information.
- B. It estimates a child's level of pain based on parents' perception.
- C. It estimates a child's level of pain utilizing behavioral and physical responses.
- D. It estimates a child's level of pain utilizing a numeric scale from 0 to 5.
Correct Answer: C
Rationale: The FLACC scale uses observable behavioral and physical responses (facial expression, leg movement, activity, cry, and consolability) to estimate pain.
A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?
- A. "I don't'd understand why I have to keep taking pills when my blood pressure is normal."
- B. "I can't see the numbness on the label to know how much selt is in food."
- C. "I feel dizzy, I'll skip my dose foe a few days."
- D. "If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor."
Correct Answer: C
Rationale: The statement by the client, "I feel dizzy, I'll skip my dose for a few days," supports the nursing diagnosis of noncompliance with medication therapy. Prazosin is typically prescribed for conditions such as hypertension or benign prostatic hyperplasia, and abruptly stopping the medication can lead to negative consequences such as rebound hypertension. The client's decision to skip doses due to feeling dizzy indicates noncompliance with the prescribed medication regimen, which can pose risks to their health. It is essential for healthcare providers to educate the client on the importance of consistent medication adherence and to address any concerns or side effects promptly.