Nokea
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: A reduced hematocrit (Hct) in a client with deep partial-thickness burns can be primarily caused by volume overload with hemodilution. In patients with burns, there is an initial shift of fluid from the intravascular space to the interstitial space, leading to a decreased intravascular volume. In response to this hypovolemia, there is an increased release of antidiuretic hormone (ADH) and aldosterone, resulting in retention of water and sodium. This volume overload leads to hemodilution, where the proportion of red blood cells to plasma decreases, causing a reduction in hematocrit levels. This scenario is a common occurrence in clients with burn injuries and helps explain the reduced hematocrit in this client.
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A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?
- A. Thin wasted extremities with a prominent abdomen
- B. Constipation
- C. Elevated hemoglobin
- D. High levels of protein
Correct Answer: A
Rationale: Kwashiorkor is a form of severe acute malnutrition characterized by a deficiency in protein intake, leading to a protein-energy malnutrition. One of the hallmark signs of kwashiorkor is an enlarged, protruding abdomen due to fluid retention in the tissues (edema), giving the appearance of a swollen belly. Additionally, individuals with kwashiorkor often have thin, wasted extremities while their abdomen appears disproportionately distended. This is known as the "big belly, skinny limbs" presentation, which arises due to the imbalance of protein and energy intake. Therefore, the nurse assessing a child with kwashiorkor should expect to find thin wasted extremities with a prominent abdomen.
Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response? a.All the girls will be normal and the other son a carrier
- A. All the girls will be carriers and one half the boys will be affected
- B. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
- C. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
- A. To reduce the risk of seizures before and after surgery
- B. To avoid intraoperative complications
- C. To reduce cerebral edema
- D. To prevent postoperative vomiting
Correct Answer: A
Rationale: The correct statement justifying the administration of the prescribed anticonvulsant phenytoin to a client before intracranial surgery is "To reduce the risk of seizures before and after surgery." Patients undergoing intracranial surgery are at an increased risk of seizures due to the manipulation of the brain tissue and the potential for increased intracranial pressure during the procedure. Administering an anticonvulsant like phenytoin before surgery helps reduce the risk of seizures both during the surgery and in the postoperative period. This proactive approach not only protects the patient from the potential harm associated with seizures but also contributes to a smoother recovery process.
A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer. Men who had cryptorchidism, a condition where one or both testicles fail to descend into the scrotum before birth, have a higher risk of developing testicular cancer compared to those without this condition. The abnormal positioning of the testicle outside the scrotum may disrupt normal testicular development and increase the likelihood of malignant transformation. Therefore, clients with a history of cryptorchidism are at increased risk for testicular cancer and warrant close monitoring and follow-up.
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
- A. 5 seconds
- B. 10 seconds
- C. 30 seconds
- D. 60 seconds
Correct Answer: C
Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.