Nokea
A nurse is teaching a client with Addison's disease about its cause. What should the nurse say?
- A. It is caused by the overproduction of growth hormone.
- B. It is caused by the lack of production of aldosterone by the adrenal gland.
- C. It is caused by excess thyroid hormone.
- D. It is caused by overactive adrenal glands.
Correct Answer: B
Rationale: The correct answer is B: Addison's disease is caused by the lack of production of aldosterone by the adrenal gland. Aldosterone is a hormone produced by the adrenal glands that helps regulate blood pressure and electrolyte balance in the body. In Addison's disease, the adrenal glands do not produce enough aldosterone, leading to symptoms like low blood pressure, weakness, and electrolyte imbalances. Choice A is incorrect because Addison's disease is not caused by the overproduction of growth hormone. Choice C is incorrect as it mentions excess thyroid hormone, which is not related to Addison's disease. Choice D is incorrect because Addison's disease is characterized by underactive, not overactive, adrenal glands.
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A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Take a warm shower every day.
- C. Resume regular activities immediately.
- D. Avoid all physical activity for the next month.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This instruction is crucial after a cataract extraction to prevent any strain on the eye during the initial healing period. Lifting heavy objects can increase intraocular pressure and potentially lead to complications. Choice B (Take a warm shower every day) is not directly related to post-operative care for a cataract extraction. Choice C (Resume regular activities immediately) is incorrect as the client should avoid strenuous activities, including heavy lifting, to allow proper healing. Choice D (Avoid all physical activity for the next month) is overly restrictive and unnecessary. It's important to provide specific, clear, and relevant instructions to support the client's recovery.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Use purified water for drinking.
- C. Limit intake of fried foods.
- D. Get vaccinated for hepatitis C.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods prepared with tap water. Tap water in certain regions may be contaminated with hepatitis-causing viruses. Using bottled or purified water for drinking alone (choice B) may not prevent exposure through food preparation. Limiting fried foods (choice C) is unrelated to preventing viral hepatitis. While getting vaccinated for hepatitis C (choice D) is important, it is not directly related to preventing exposure through contaminated tap water. Therefore, the most effective preventive measure is to avoid foods prepared with tap water to reduce the risk of acquiring viral hepatitis.