Nokea
A nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents the major stressor of hospitalization for these four patients?
- A. Separation anxiety
- B. Loss of control
- C. Fear of bodily injury
- D. Fear of pain
Correct Answer: A
Rationale: Separation anxiety is the major stressor of hospitalization for these young patients. Toddlers and preschoolers are at a critical stage of development where they are developing close attachments to their primary caregivers. Being separated from their parents or primary caregivers when admitted to the hospital can lead to feelings of fear, distress, and insecurity. This separation can significantly impact their emotional well-being and overall hospital experience. Loss of control, fear of bodily injury, and fear of pain are also stressors associated with hospitalization, but separation anxiety is the primary concern for these young patients due to their developmental stage.
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A 16-year-old discusses his recent diagnosis of lupus with the nurse. Which statement best describes adolescent thinking regarding the future?
- A. Adolescents are preoccupied with the present.
- B. Adolescents are beginning to think abstractly and consider future possibilities.
- C. Adolescents think only in concrete terms.
- D. Adolescents are overly concerned with past events.
Correct Answer: B
Rationale: During adolescence, abstract thinking develops, allowing teens to envision future possibilities.
When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
- A. Taking two normal breaths before use.
- B. Sitting upright before use.
- C. Inhaling deeply to reach target.
- D. Exhaling deeply to reach target.
Correct Answer: D
Rationale: When using an incentive spirometer, the patient should inhale deeply to reach the target volume indicated by the marker. Exhaling deeply does not achieve the objective of the incentive spirometer, which is to encourage deep inhalation. If the patient exhales deeply to reach the target, further teaching and clarification about the proper technique of using the spirometer are needed. The correct technique involves inhaling deeply to expand the lungs and help improve lung function.
In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit?
- A. Elevated blood pressure
- B. Increased pulse rate
- C. Cyanosis of the nail beds
Correct Answer: B
Rationale: In addition to weakness and fatigue, the nurse should expect Aisa to exhibit an increased pulse rate. Weakness and fatigue are common symptoms of anemia, a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can lead to the heart working harder to pump oxygen-rich blood to the body, resulting in an increased pulse rate. Therefore, it is important for the nurse to assess for signs of tachycardia (elevated heart rate) in a patient with anemia.
A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?
- A. To determine the severity of the disorder
- B. To identify signs of fluid retention
- C. To determine the location of discomfort
- D. To determine clients response to therapy
Correct Answer: A
Rationale: Evaluating the client's BUN, creatinine, and serum electrolyte levels when being treated for acute pyelonephritis is crucial in determining the severity of the disorder. BUN and creatinine levels are indicators of renal function, where elevated levels may suggest impaired kidney function due to inflammation in the kidneys from pyelonephritis. Abnormal electrolyte levels, such as potassium and sodium, may also reflect the impact of the infection on renal function. Therefore, monitoring these test results helps healthcare providers assess how well the kidneys are functioning and the severity of the pyelonephritis to guide appropriate treatment decisions.
Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
- A. 900 CD 4+ cells
- B. 500 CD 4+ cells
- C. 700 CD 4+ cells
- D. 200 CD 4+ cells
Correct Answer: D
Rationale: The nurse would evaluate 200 CD 4+ cells as laboratory data that support the occurrence of AIDS. In patients with AIDS, there is a significant decrease in the CD4+ T-lymphocyte count, typically falling below 200 cells/mm³. This low CD4+ cell count increases the risk of opportunistic infections and indicates severe immune suppression, which is characteristic of AIDS. A CD4+ count of 200 or less is an important criterion for the diagnosis of AIDS according to the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines.