Nokea
During a routine check-up, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
- A. Muscle weakness
- B. Painful subcutaneous nodules
- C. Joint abnormalities
- D. Gait disturbances
Correct Answer: C
Rationale: When evaluating a client with rheumatoid arthritis, the nurse should check for joint abnormalities first because it is the most obvious manifestation of the disease. Rheumatoid arthritis primarily affects the joints, causing inflammation, pain, stiffness, and potentially deformity over time. Assessing for joint abnormalities can provide crucial information about the severity and progression of the disease, guiding further assessment and intervention plans. Muscle weakness, painful subcutaneous nodules, and gait disturbances can also be present in rheumatoid arthritis, but joint abnormalities are the hallmark feature that should be assessed initially.
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Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
- A. The adverse effect of mastectomy are immediate
- B. The wound of the surgery is highly contagious and the client should exercise isolation precautions immediately after the procedure
- C. Most clients are not hospitalized long after a mastectomy
- D. The suicidal tendencies in the women undergoing a mastectomy are high
Correct Answer: C
Rationale: Most clients are not hospitalized long after a mastectomy. This is a key reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy. Typically, clients undergoing mastectomy have shorter hospital stays, often as part of the trend toward faster postoperative recovery and reduced healthcare costs. By ensuring that clients have appropriate home care arrangements and understand postoperative instructions early on, healthcare providers can support a smooth transition from the hospital to the home environment, promoting optimal recovery and outcomes for the client.
Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?
- A. Dysmenorrhea and oliguria
- B. Tachycardia and tachypnea
- C. Heat intolerance and increased blood pressure
- D. Lowered body temperature and brittle nails
Correct Answer: B
Rationale: An adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa is likely to exhibit tachycardia (rapid heart rate) and tachypnea (rapid breathing). These symptoms are common manifestations of the body's response to malnutrition and starvation. Tachycardia occurs as a compensatory mechanism to maintain an adequate supply of oxygen to vital organs, while tachypnea helps to eliminate excess carbon dioxide due to metabolic imbalances. It is essential for the nurse to recognize these signs during the physical assessment as they indicate the severity of the condition and the need for immediate intervention to prevent further complications. Dysmenorrhea and oliguria, heat intolerance and increased blood pressure, and lowered body temperature and brittle nails are not typically associated with the physical manifestations of anorexia nervosa.
The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
- A. Elevated serum acetone level
- B. Serum alkalosis
- C. Serum ketone bodies
- D. Below-normal serum potassium level
Correct Answer: D
Rationale: Hyperosmolar hyperglycemic nonketonic syndrome (HHNS) is characterized by extremely elevated blood glucose levels without significant ketosis. Unlike diabetic ketoacidosis (DKA), patients with HHNS usually do not have high levels of ketone bodies in their blood or urine. Therefore, the nurse should anticipate below-normal serum potassium levels in a client with HHNS, as hyperglycemia can lead to profound potassium losses through osmotic diuresis. Monitoring and treating electrolyte imbalances, including hypokalemia, are crucial in managing HHNS. It is important to correct these imbalances promptly to prevent further complications.
While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
- A. It promotes the clients compliance with therapy
- B. It minimizes the chances of adverse effects
- C. It promotes a strict food and fluid intake habit
- D. It raises the self esteem of the client
Correct Answer: A
Rationale: It is essential for a nurse to ensure that the client is actively involved in the development of the plan for proportionate distribution of restricted fluid volumes because it promotes the client's compliance with therapy. When the client participates in creating the plan, they are more likely to understand the importance of following it and be motivated to adhere to the recommended fluid restrictions. This active involvement fosters a sense of ownership and responsibility, leading to better treatment outcomes and improved overall health.
All the following are compatible with the definition of obstructive sleep apnea EXCEPT
- A. episodes of prolonged upper airway obstruction
- B. repeated apnea
- C. 230% reduction in airflow
- D. 2-30% O2 desaturation
Correct Answer: D
Rationale: Oxygen desaturation of 2-30% is too low to define mild-to-moderate sleep apnea.