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After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?
- A. Make a referral for social services at home.
- B. Continue to limit daily fluid intake to 500 mL.
- C. Begin preparing the client for discharge home.
- D. Recommend strict intake and output monitoring.
Correct Answer: C
Rationale: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
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A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Gastroccult positive emesis.
- B. Strong foul smelling flatus.
- C. Complaint of poor night vision.
- D. Loose bowel movements.
Correct Answer: A
Rationale: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)
- A. Abdominal obesity.
- B. Blood pressure of 150/96 mm Hg.
- C. Elevated high density lipoproteins.
- D. Increased triglyceride levels.
- E. Hyperglycemia.
- F. Hypothyroidism.
Correct Answer: A,B,D,E
Rationale: Abdominal obesity, elevated blood pressure, increased triglyceride levels, and hyperglycemia are components of metabolic syndrome that increase the risk of diabetes and vascular disease, requiring intervention.
A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- A. Pupillary changes to ipsilateral dilation.
- B. Left-sided facial drooping and dysphagia.
- C. Orientation to person and place only.
- D. Unequal bilateral hand grip strengths.
Correct Answer: A
Rationale: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.
A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
- A. Rocky Mountain spotted fever.
- B. Intracerebral hemorrhage.
- C. Cerebrovascular accident (CVA).
- D. Meningococcal meningitis.
Correct Answer: D
Rationale: Meningococcal meningitis is characterized by severe headache, fever, nuchal rigidity, and a petechial rash, which are consistent with the client's symptoms.