Nokea
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
- A. Serum sodium of 185 mEq/L
- B. Urine output of 3000 mL per hour.
- C. Blood pressure of 90/60 mmHg.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: A
Rationale: A serum sodium level of 185 mEq/L indicates severe hypernatremia, which is life-threatening and requires immediate intervention.
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Coxsackie viruses are implicated in:
- A. Herpangina
- B. Dermatitis herpetiformis
- C. Meningitis
- D. Orchitis
Correct Answer: A
Rationale: Coxsackie viruses are a common cause of herpangina. They can also cause meningitis and orchitis, but dermatitis herpetiformis is not associated with Coxsackie viruses.
Distal renal tubular acidosis:
- A. Is characterised by hypokalaemia
- B. May be primary or secondary
- C. Presents with growth failure in infancy
- D. Urinary pH is usually < 5
Correct Answer: B
Rationale: Distal renal tubular acidosis (RTA) can be either primary (inherited) or secondary (acquired due to other conditions), affecting acid excretion in the distal tubule.
A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
- A. Re-orient the client to his present location and circumstances
- B. Confirm that this is an effective technique to help with ambulation
- C. Assist the client to a carpeted area where he can walk more easily
- D. Plan to assess the client's cognition after returning to his room
Correct Answer: B
Rationale: Pretending to step over a crack is a known technique that can help clients with PD overcome freezing episodes.
A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?
- A. Thrombus formation
- B. Infection
- C. Bronchospasm
- D. Heart failure
Correct Answer: A
Rationale: After a cardiac catheterization, the nurse must monitor for thrombus formation as it is a common complication in the first 24 hours.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Black ulcers and dependent rubor
- B. Irregular ulcer shapes and severe edema
- C. Absent pedal pulses and shiny skin
- D. Hairless lower extremities and cool feet
Correct Answer: B
Rationale: Venous ulcers are typically irregular in shape and associated with severe edema, while arterial ulcers are more likely to present with absent pulses and cool extremities.