Nokea
A nurse is assessing a 5 year old with a history of heart failure. Which finding indicates that the child has adequate cardiac output?
- A. Urine output of 30 mL/h
- B. Heart rate of 120 beats/min
- C. Cap refill time of 10 to 15 sec
- D. Bilateral crackles heard on auscultation.
Correct Answer: A
Rationale: Adequate cardiac output is a measure of how well the heart is able to pump blood effectively to meet the body's metabolic demands. An adequate cardiac output ensures sufficient oxygen and nutrients are delivered to the tissues and organs. One of the most reliable indicators of adequate cardiac output is urine output. A urine output of at least 1 mL/kg/hour, which translates to around 30 mL/hour in a 5-year-old child, indicates adequate perfusion and renal function. In heart failure, decreased cardiac output may lead to decreased renal perfusion, resulting in a decreased urine output, so a stable or increased urine output suggests adequate cardiac output.
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A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends's behavior shows that they aren't true friends
Correct Answer: C
Rationale: It is important for the nurse to listen and show interest as the client expresses their feelings in this situation. The client's emotional distress is a valid response to feeling abandoned by friends and family during a difficult time. By providing a supportive and empathetic presence, the nurse can help the client feel valued and understood, promoting emotional well-being and potentially increasing the client's sense of comfort and trust in the healthcare setting. This approach validates the client's feelings and fosters therapeutic communication, which is crucial in providing holistic care to individuals with complex health needs such as AIDS and Pneumocystis carinii pneumonia. It is essential to acknowledge and address the client's emotional needs in addition to their physical care.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
Undescended testis is a risk factor for the development of which of the following tumors?
- A. rhabdomyosarcoma
- B. leukemia
- C. yolk sac tumor
- D. lymphoma
Correct Answer: C
Rationale: Undescended testis is a well-documented risk factor for yolk sac tumors and other testicular cancers.
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client's nursing care plan? Choose all that apply
- A. Administer prescribed nephrotoxic drugs
- B. Encourage ambulation and liberal fluid
- C. Observe aseptic principles when changing intake
- D. Provide a comfortable position
Correct Answer: B
Rationale: A. Administer prescribed nephrotoxic drugs - This measure is not appropriate for the client's care plan as nephrotoxic drugs can further harm the kidneys, exacerbating the condition of renal calculi.
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The client's symptoms of dizziness upon standing up, along with nosebleeds and blurred vision, are suggestive of postural hypotension. Postural hypotension, also known as orthostatic hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, blurred vision, and in some cases, nosebleeds. It is more common in older adults, like the 78-year-old male client in this scenario. Therefore, the nurse should assess for postural hypotension in this client to manage his symptoms and prevent complications.