Nokea
Children with severe traumatic brain injury (TBI) may experience autonomic dysfunction characterized by all the following EXCEPT
- A. elevated temperature
- B. elevated heart rate
- C. elevated respiratory rate
- D. lowered blood pressure
Correct Answer: D
Rationale: Autonomic dysfunction in TBI typically involves elevated temperature, heart rate, and respiratory rate due to dysregulation of the autonomic nervous system. Lowered blood pressure is less common and may indicate hypovolemia or other conditions rather than autonomic dysfunction.
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When caring for a client, whose being treated for hyperthyroidism, it's important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client's periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: When caring for a client with hyperthyroidism, it is important to monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy. Treatment for hyperthyroidism often involves thyroid replacement therapy to restore the balance of thyroid hormones in the body. Monitoring for signs and symptoms of overmedication or undermedication is crucial to ensure the client's health and well-being. Restlessness, sweating, and weight loss can be indicators of an imbalance in thyroid hormone levels and may require adjustments in medication dosage. Regular monitoring and communication with healthcare providers are essential in managing the client's condition effectively.
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which of the following glands?
- A. Adrenal cortex
- B. Adrenal medulla
- C. Pancreas
- D. none of the above
Correct Answer: A
Rationale: Primary hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal cortex. Aldosterone is a hormone produced by the adrenal glands that plays a key role in regulating blood pressure and electrolyte balance in the body. When there is an overproduction of aldosterone, it can lead to increased sodium retention and potassium excretion, resulting in hypertension. Therefore, in this case, the client's hypertension is caused by excessive hormone secretion from the adrenal cortex, making option A the correct answer.
Which manifestation is more specific to occur in anaplastic large cell lymphoma (ALCL) than other types of non-Hodgkin lymphoma?
- A. primary bone marrow involvement
- B. intestinal involvement
- C. CNS involvement
- D. primary mediastinal involvement
Correct Answer: D
Rationale: Primary mediastinal involvement is a hallmark feature of ALCL.
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
- A. Positive family history
- B. Infectious agents or toxins
- C. Acute or chronic blood loss
- D. Inadequate dietary intake
Correct Answer: C
Rationale: Pernicious anemia is primarily caused by the body's inability to absorb vitamin B12 due to a lack of intrinsic factor produced by the stomach. However, chronic blood loss can also lead to anemia by depleting the body's iron stores necessary for the production of healthy red blood cells. Acute blood loss can quickly lower the hemoglobin levels in the blood, while chronic blood loss can lead to iron-deficiency anemia over time. Therefore, in assessing clients for pernicious anemia, the nurse should be alert for the risk factor of acute or chronic blood loss as a potential cause of anemia.
Fentanyl is used as analgesia during operative and postoperative procedures. Which of the following conditions is NOT associated with fentanyl use?
- A. Tachycardia
- B. Hypotension
- C. Nausea and vomiting
- D. Acidosis
Correct Answer: D
Rationale: Fentanyl typically causes hypotension, nausea, and vomiting, but it does not cause acidosis.