Nokea
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.
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The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection?
- A. Increased fluid intake
- B. Short urethra in young girls
- C. Prostatic secretions in males
- D. Frequent emptying of the bladder
Correct Answer: B
Rationale: One of the factors that predisposes the urinary tract to infection is a short urethra in young girls. The shorter urethra compared to boys makes it easier for bacteria to travel up the urinary tract and cause infections. This anatomical difference in young girls increases their susceptibility to urinary tract infections compared to boys. In boys, the longer length of the urethra provides a natural barrier for bacteria to enter the bladder, reducing the risk of infection.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: For male clients over age 50, early identification of prostate cancer involves a combination of regular digital rectal examination and PSA test. The digital rectal examination allows a healthcare provider to manually assess the size, shape, and consistency of the prostate gland, looking for any abnormalities such as nodules or hard areas that may indicate prostate cancer. The PSA test measures the level of prostate-specific antigen in the blood, with elevated levels potentially signaling the presence of prostate cancer. Yearly screening using both these methods increases the chances of early detection and optimal management of prostate cancer in older male clients. Regular monitoring helps in identifying the disease at an earlier, more treatable stage, improving outcomes and prognosis.
Which is a major complication in a child with chronic renal failure?
- A. Hypokalemia
- B. Metabolic alkalosis
- C. Water and sodium retention
- D. Excessive excretion of blood urea nitrogen
Correct Answer: C
Rationale: A major complication in a child with chronic renal failure is water and sodium retention, leading to fluid overload and hypertension. Because the kidneys are not functioning properly, they are unable to regulate fluid and sodium levels in the body effectively. This can result in edema, increased blood pressure, and potential heart complications. Monitoring and managing fluid and sodium intake are essential in managing this complication in children with chronic renal failure.
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician's orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Monitoring electrolytes for hypokalemia (low potassium levels) and hypocalcemia (low calcium levels) is essential in the plan of care for a client. These electrolyte imbalances can be common in cases of dehydration and vomiting, and they can lead to serious complications if not detected and managed promptly. Hypokalemia can cause cardiac arrhythmias and muscle weakness, while hypocalcemia can lead to neuromuscular irritability and seizures. By monitoring electrolyte levels, the nurse can identify any imbalances early and take necessary interventions to prevent adverse outcomes.