Nokea
A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of:
- A. urinary excess
- B. hyperpituitarism
- C. urinary deficit
- D. hyperthyroidism
Correct Answer: C
Rationale: Elevated cortisol levels can lead to sodium and fluid retention and potassium deficit, resulting in urinary deficit. This imbalance in electrolytes and fluid can cause a decrease in urinary output. Choices B, hyperpituitarism, and D, hyperthyroidism, are incorrect as they do not directly relate to the symptoms expected with elevated cortisol levels. Option A, urinary excess, is also incorrect as high cortisol levels typically lead to fluid retention and urinary deficit, not excess.
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A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:
- A. no relation to the blood transfusion.
- B. graft-versus-host disease (GVHD).
- C. myelosuppression.
- D. an allergic reaction to a recent medication.
Correct Answer: B
Rationale: In this scenario, the symptoms of fever, liver abnormalities, rash, and diarrhea in an immunocompromised client a month after a blood transfusion are indicative of graft-versus-host disease (GVHD). GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can manifest within a month of the transfusion. While choices 1 and 4 are plausible, it is crucial for the nurse to consider the possibility of GVHD in immunocompromised transfusion recipients due to the significant risk. Myelosuppression, choice C, typically presents with decreased blood cell counts and is not consistent with the symptoms described. An allergic reaction to medication, choice D, would present with different manifestations such as itching, hives, or anaphylaxis, which are not described in the scenario.
What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?
- A. HIV.
- B. HSV 1, HSV 2, and VZV.
- C. CMV
- D. Influenza A viruses.
Correct Answer: B
Rationale: Acyclovir (Zovirax) is the drug of choice for herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) infections. It works by inhibiting viral DNA replication. Acyclovir is excreted unchanged in the urine, so caution is needed in renal impairment. Choice A, HIV, is incorrect as acyclovir is not the drug of choice for HIV. Choice C, CMV, is incorrect as acyclovir is not the preferred treatment for cytomegalovirus (CMV) infections. Choice D, Influenza A viruses, is incorrect as acyclovir is not used to treat influenza viruses.
A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?
- A. "I will call your physician to see if we can start some ginger."?
- B. "We don't use home remedies in this clinic."?
- C. "Herbs are not as effective as regular medicines."?
- D. "Just eat some dry crackers instead."?
Correct Answer: A
Rationale: The correct response is to offer to consult with the physician regarding the use of ginger, showing cultural sensitivity. Ginger is known to help relieve nausea, especially in pregnancy. Choice A is the correct answer as it respects the client's preference for a home remedy and involves the physician in the decision-making process. Choice B dismisses the client's preference for a home remedy without exploring its potential benefits. Choice C makes a generalized statement discrediting the effectiveness of herbs, which is not evidence-based and disregards the client's beliefs. Choice D offers an alternative without addressing the client's specific request, failing to acknowledge the client's autonomy and cultural background.
A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?
- A. "I will call your physician to see if we can start some ginger."?
- B. "We don't use home remedies in this clinic."?
- C. "Herbs are not as effective as regular medicines."?
- D. "Just eat some dry crackers instead."?
Correct Answer: A
Rationale: The correct response is appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?
- A. increased platelet count
- B. increased fibrinogen
- C. decreased fibrin split products
- D. decreased bleeding
Correct Answer: B
Rationale: Effective Heparin therapy should halt the process of intravascular coagulation, leading to increased availability of fibrinogen. Heparin interferes with thrombin-induced conversion of fibrinogen to fibrin. Therefore, an increased fibrinogen level indicates a positive response to Heparin therapy. While increased platelet count and decreased bleeding are positive outcomes, the specific indicator for Heparin therapy response is the increase in fibrinogen level. Decreased fibrin split products would also be a positive response, but an increase in fibrinogen directly reflects the impact of Heparin therapy.