Nokea
What are the nursing interventions for a client with thalassemia?
- A. Maintain the client on bed rest and protect him or her from infections
- B. Ambulate the client frequently
- C. Advise drinking 3 quarts (L) of fluid per day
- D. Instruct the client to elevate the lower extremities as much as possible
Correct Answer: A
Rationale: Thalassemia is a genetic blood disorder that results in the reduced production of hemoglobin and red blood cells. Nursing interventions for a client with thalassemia aim to manage symptoms and prevent complications. Maintaining the client on bed rest helps conserve energy and prevent fatigue, which is commonly experienced due to anemia. Protecting the client from infections is crucial because individuals with thalassemia are at a higher risk of infections due to their weakened immune system. By minimizing the risk of infections, nurses can help prevent further complications in clients with thalassemia.
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Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: A decreasing level of consciousness is a symptom often associated with increased intracranial pressure (ICP). When the pressure inside the skull rises, it can compress and damage the brain, leading to a deterioration in consciousness. Common causes of increased ICP include traumatic brain injury, brain tumors, and infections. As ICP continues to rise, it can result in serious consequences such as brain herniation, which can be life-threatening if not promptly managed. Therefore, a decreasing level of consciousness should raise concerns about increased ICP and warrant immediate medical evaluation and intervention.
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi's sarcoma
Correct Answer: D
Rationale: Kaposi's sarcoma is the most common AIDS-related cancer. It is a type of cancer that usually appears as lesions on the skin, mouth, or internal organs. Kaposi's sarcoma is caused by human herpesvirus 8 (HHV-8) and is more likely to develop in individuals with weakened immune systems, such as those with AIDS. The risk of developing Kaposi's sarcoma is higher in people with HIV/AIDS due to the weakened immune system's inability to fight off infections and certain cancers. Regular assessment for signs and symptoms of Kaposi's sarcoma is important in people living with AIDS in order to detect and treat it early.
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: Zidovudine (azidothymidine, AZT [Retrovir]) is an antiretroviral medication used to treat human immunodeficiency virus (HIV) infection. One of the potential adverse effects of zidovudine is bone marrow suppression, which can lead to decreased production of blood cells including platelets. Monitoring the platelet count is essential because a low platelet count (thrombocytopenia) can result in an increased risk of bleeding and bruising. Therefore, regular monitoring of platelet count is crucial to detect and manage this potential adverse effect promptly in patients receiving zidovudine therapy. Monitoring other laboratory tests such as RBC count, serum calcium, and fasting blood glucose may also be important for assessing overall health status, but platelet count monitoring takes priority due to the risk of thrombocytopenia associated with zidovudine therapy.
Which of the following symptoms most likely indicates that an infusion is infiltrated?
- A. Redness at the site
- B. Pain at the site
- C. Puffiness at the site
- D. Exudate at the site
Correct Answer: C
Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.
The nurse understands that which of the ff. best describes the action of enalapril maleate (Vasotec)?
- A. It decreases levels of angiotensin II
- B. It dilates the arterioles and veins
- C. It adjusts the extracellular volume
- D. It decreases cardiac output
Correct Answer: A
Rationale: Enalapril maleate (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor. The main action of ACE inhibitors like enalapril is to decrease the levels of angiotensin II in the body. Angiotensin II is a potent vasoconstrictor that plays a role in regulating blood pressure, stimulating aldosterone secretion, and promoting sodium and water retention. By inhibiting the conversion of angiotensin I to angiotensin II, enalapril reduces vasoconstriction and aldosterone secretion, leading to vasodilation, decreased blood pressure, and ultimately decreased levels of angiotensin II. This mechanism allows for the dilation of arterioles and veins, reduction in cardiac afterload, and ultimately decreases the workload of the heart.