Nokea
A healthcare provider is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
- A. Substernal retractions
- B. Hematuria
- C. Temperature 37.9°C (100.2°F)
- D. Sneezing
Correct Answer: A
Rationale: Substernal retractions are a concerning sign of respiratory distress and can indicate acute chest syndrome, a severe complication of sickle-cell anemia. It results from vaso-occlusion in the pulmonary vasculature, leading to impaired oxygenation. Prompt reporting of this symptom is crucial for early intervention to prevent further complications. Hematuria, a high temperature, and sneezing are not specific manifestations of acute chest syndrome and would not warrant immediate notification to the provider in this context.
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A healthcare provider is assessing a client who has left-sided heart failure. Which of the following should the healthcare provider identify as a manifestation of pulmonary congestion?
- A. Frothy, pink sputum
- B. Jugular vein distention
- C. Weight gain
- D. Bradypnea
Correct Answer: A
Rationale: Pulmonary congestion is a common manifestation of left-sided heart failure. When the left side of the heart fails, blood backs up into the lungs, leading to pulmonary congestion. This can result in symptoms such as frothy, pink-tinged sputum due to the presence of blood in the respiratory secretions. Jugular vein distention, weight gain, and bradypnea are also associated with heart failure, but frothy, pink sputum specifically indicates pulmonary congestion in this scenario.
When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?
- A. Psychologist
- B. Social worker
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.
A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client.
- B. Evaluate the client's understanding of life-sustaining measures.
- C. Determine the client's preferences about post-mortem care.
- D. Request a conference with the client's family
Correct Answer: B
Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.
When discussing group treatment and therapy with a client, which characteristic should the nurse include as being a characteristic of a therapeutic group?
- A. The group is organized in an autocratic structure.
- B. The group encourages members to focus on a particular issue
- C. The group must be led by a licensed psychiatrist.
- D. The group encourages clients to form dependent relationships.
Correct Answer: B
Rationale: In therapeutic groups, the focus is often on addressing specific issues or topics. This approach allows group members to concentrate on their concerns, share experiences, and work towards common goals. Autocratic structures, mandatory leadership by a licensed psychiatrist, or fostering dependent relationships are not typical characteristics of therapeutic groups.
Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
- A. Hyperthyroidism.
- B. Thrombophlebitis.
- C. Diverticulosis.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Thrombophlebitis, which is inflammation of a vein with the formation of a clot, is a contraindication to the use of oral contraceptives due to an increased risk of thromboembolism. Clients with a history of thrombophlebitis or thromboembolic disorders should avoid oral contraceptives to prevent further complications like deep vein thrombosis or pulmonary embolism.