Nokea
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
- A. Infection.
- B. Confusion.
- C. Ineffective coughing and deep breathing.
- D. Difficulty chewing solid foods.
Correct Answer: C
Rationale: Kyphosis and muscle atrophy impair chest expansion and cough effectiveness, increasing pneumonia complications. Ineffective coughing and deep breathing is the priority to clear secretions and prevent worsening infection. Infection is already present. Confusion and chewing difficulties are less immediate concerns.
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Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:
- A. The effects of thyroid hormone replacement therapy and will diminish over time.
- B. Related to thyroid hormone replacement therapy and will not diminish over time.
- C. A normal part of having a chronic illness.
- D. Most likely related to low thyroid hormone levels and will improve with treatment.
Correct Answer: D
Rationale: Low thyroid hormone levels in hypothyroidism can cause depression and sadness, which typically improve with thyroid hormone replacement therapy.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
- A. A low, grade 1 intensity mitral regurgitation murmur.
- B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.
- C. The client has become more somnolent.
- D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Correct Answer: C
Rationale: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate