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.
You may also like to solve these questions
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: Diagnostic study findings in multiple myeloma often include the presence of Bence Jones protein in the urine. Bence Jones protein is a type of abnormal protein (immunoglobulin light chain) produced by the abnormal plasma cells in multiple myeloma. Its presence in the urine can be detected through urine protein electrophoresis and is a characteristic feature of the disease. Other common findings in multiple myeloma include hypercalcemia, elevated serum creatinine level, and high serum protein level due to the excess production of monoclonal immunoglobulins.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.
The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family?
- A. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
- B. Instruct the parents that the child will probably need to have daily enemas.
- C. Suggest the use of stimulant cathartics weekly.
- D. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
Correct Answer: D
Rationale: The most appropriate response for the nurse to include in the discussion with the family of a child with a history of encopresis is to reassure them that most problems are resolved successfully, with some relapses during periods of stress. Encopresis is a common disorder in childhood, characterized by the repeated passage of feces in inappropriate places. It is often related to chronic constipation and fecal impaction. Treatment for encopresis includes addressing the underlying constipation through interventions like dietary changes, behavioral therapies, and possibly medications. It is important for the nurse to educate the family that although it may take time and effort, most children improve with treatment. Reassuring the family that relapses during periods of stress are to be expected can help to alleviate some of their anxiety and encourage them to continue with the treatment plan.
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: During an ophthalmic assessment, the nurses are expected to observe the following carefully:
The health-care provider diagnosed a child with Legg-Calve-Perthes disease. The parents expressed their concern to you that their child's leg will be amputated. How should you respond?
- A. It is too soon to determine if amputation is necessary.
- B. No amputation is necessary because the child will make a full recovery once the disease runs its course.
- C. The health-care provider is the best person to talk to you about amputation.
- D. Not all children who have the disease require amputation.
Correct Answer: D
Rationale: Legg-Calve-Perthes disease, also known as Perthes disease, is a condition where there is a temporary loss of blood supply to the hip, leading to the breakdown of the hip joint. While in severe cases amputation may be considered as a treatment option, it is important to reassure the parents that not all children with Legg-Calve-Perthes disease require amputation. The course of treatment will depend on the severity of the condition and the individual child's response to different therapies. Therefore, it is crucial to emphasize that amputation is not the automatic outcome for all cases of Legg-Calve-Perthes disease. Encouraging the parents to discuss their concerns with the healthcare provider can provide more specific information and guidance tailored to their child's condition.