Nokea
An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?
- A. Administer a prescribed sedative
- B. Encourage client to drink water
- C. Apply a high flow venturi mask
- D. Assist her to an upright position
Correct Answer: D
Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.
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Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?
- A. Are you sure your child has iron deficiency anemia?
- B. This happens when the maternal stores of iron are depleted at about 6 months.
- C. This anemia is caused by blood loss.
- D. The child may not have had it for a long time.
Correct Answer: B
Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.
When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct Answer: B
Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.
Which pathology is associated with an asthma condition?
- A. Chronic dilation and inflammation of the bronchi.
- B. Recurrent spasms of the airways accompanied by edema and mucus production.
- C. Progressive loss of lung function due to destruction of alveolar walls.
- D. Infection of the lung parenchyma.
Correct Answer: B
Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.
How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?
- A. Hand assistance
- B. Leg crawling
- C. Gowers sign
- D. Bright sign
Correct Answer: C
Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.
A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Evidence of spread of the disease to the kidney.
- B. Confirmation of the autoimmune disease process.
- C. Representative of a decline in the client's condition.
- D. Indication of the onset of joint degeneration.
Correct Answer: B
Rationale: The correct interpretation of elevated serum rheumatoid factor in a client with rheumatoid arthritis is confirmation of the autoimmune disease process. Rheumatoid factor is a marker for autoimmune activity, thus confirming the diagnosis of rheumatoid arthritis. Choice A is incorrect as elevated rheumatoid factor does not specifically indicate spread of the disease to the kidney. Choice C is incorrect as elevated rheumatoid factor does not always represent a decline in the client's condition. Choice D is incorrect as elevated rheumatoid factor is not an indication of the onset of joint degeneration, but rather points towards autoimmune activity.