Nokea
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
- A. Ecchymotic blood accumulations.
- B. Evidence of patches of lost hair.
- C. Episodic complaints of pruritus.
- D. Erythema of the localized lesions.
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.
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History and Physical
Initial vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had poor appetite and was not able to go for her scheduled dialysis 2
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a sinus tachycardiahyperkalemiahypermagnesemiahypokalemia.
- A. Sinus tachycardia
- B. Hyperkalemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: B
Rationale: The client's history of ESRD, missed dialysis, and symptoms (muscle cramps, tingling, weakness) suggest hyperkalemia, which can cause cardiac arrhythmias like sinus tachycardia. Other options are less consistent with the clinical picture.
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
- A. Muscle cramps
- B. Tingling sensation in her arms and legs
- C. Lightheadedness
- D. Fatigue
- E. Generalized weakness
Correct Answer: A,B,C
Rationale: Muscle cramps, tingling sensation, and lightheadedness are signs of electrolyte imbalance, likely due to missed dialysis, which can lead to serious complications like cardiac arrhythmias. The nurse should monitor vital signs, neurological status, and notify the physician.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.
The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.
Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Restrict visitors to family members only.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Reinforce statements regarding a will to live and realistic plans for the future.
Correct Answer: B,D,E
Rationale: Discussing suicide plans, encouraging expression of suicidal thoughts, and reinforcing hope are critical for safety and therapeutic support. Restricting visitors or limiting video games are less relevant.