Nokea
Drag words from the choices below to fill in the blank/blanks.The nurse recognizes that furosemide was effective as evidenced by------------,-----------------, and ------------------
- A. 2+ peripheral edema
- B. Increased urine output
- C. Reduced urinary hesitancy
- D. Reduced cholesterol level
- E. Reduced work of breathing
Correct Answer: A,B,E
Rationale: Loop diuretics (eg, furosemide) block renal reabsorption of sodium, chloride, and potassium, which increases fluid excretion
in the urine (ie, diuresis). Diuresis decreases intravascular volume, resulting in decreased peripheral edema (eg, from 3+ to
2+). In addition, as fluid volume decreases, pulmonary congestion improves, thereby resulting in improved oxygen exchange
and reduced work of breathing
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The nurse is reinforcing home care teaching to the client. Which statement by the client requires the nurse to provide further instruction?
- A. I should ask family members to bring prepared meals to me." (13%)
- B. "I should eat small, frequent meals every 2-3 hours." (16%)
- C. I will avoid drinking fluids with my meals." (30%)
- D. I will eat hot soups to settle my stomach." (38%)
Correct Answer: D
Rationale: Self-management of hyperemesis gravidarum is an important component of discharge teaching. The goal of home care is to prevent nausea
and vomiting and promote appropriate nutritional intake and weight gain, which can support a healthy pregnancy.
Some triggers for nausea and vomiting include an empty or overly full stomach, strong food odors, and greasy or fatty foods. It is often
recommended that clients eat cold or bland foods due to the increased aromas associated with hot foods. Therefore, the nurse should
provide further teaching to this client who plans to eat hot soup because this may precipitate nausea (Option 4). The nurse can suggest
eating foods such as toast, crackers, nuts, or cold cereal.
For each client finding below, click to specify if the finding is consistent with the disease process of behavior regression,diabetes mellitus, or urinary tract infection. Each finding may support more than one disease process.
- A. Fatigue
- B. Irritability
- C. Polydipsia
- D. Urinary frequency
- E. Nocturnal enuresis
Correct Answer:
Rationale: Behavior regression is the return to a previous behavior as an act of coping. This may be caused by a stressful event (eg,
new school, parental divorce, relocation). Clinical findings may include withdrawal or the return of previous behaviors that
resemble toddlerhood (eg, temper tantrums [fatigue, irritability], nocturnal enuresis).
Diabetes mellitus (DM) is a metabolic disorder characterized by insulin deficiency (type 1 DM) or resistance (type 2 DM),
which leads to increased blood glucose levels (ie, hyperglycemia) and signs of cellular starvation (eg, fatigue, irritability,
weight loss) from decreased glucose use. Glucose increases the osmolality of blood, which pulls water into the intravascular
space and leads to excessive urination (eg, urinary frequency, nocturnal enuresis). As the kidneys excrete excess glucose,
the body loses water, resulting in hypovolemia and signs of dehydration (eg, increased thirst [polydipsial, dry mucous
membranes).
A urinary tract infection is an infection of the urethra, bladder, ureters, and/or kidneys. Common manifestations include
fatigue, fever, painful urination (ie, dysuria), urinary frequency and urgency, and nocturnal enuresis. Irritability may be a
sign of illness in a child who has difficulty verbalizing or understanding the cause of the symptoms. Although increased urinary
frequency is seen (due to bladder irritation), volume is not excessive (unlike osmotic diuresis of DM); therefore, clients are not
dehydrated and would not report polydipsia.
Select below the 4 findings that are most concerning at this time.
- A. controlled hypertension, hypercholesterolemia, and mitral valve prolapse and regurgitation.
- B. T 100.4 F (38 C),
- C. Thin, brown longitudinal lines on
several nail beds. - D. 2 teeth extracted 3 weeks ago;
- E. general malaise, fever and chills, night sweats, fatigue,
and poor appetite. - F. erythematous macular lesions on both palms
Correct Answer: B,C,D,F
Rationale: This client has multiple findings concerning for infective endocarditis (IE), which occurs when an infectious organism enters the
innermost layer of the heart (ie, endocardium) and forms a vegetation on a heart valve. Findings concerning for IE include:
• Recent tooth extraction: Dental procedures (eg, tooth extraction) increase the risk for infectious organisms entering the
bloodstream, potentially leading to IE. Other risk factors include a history of IV drug use, presence of a distant infection
(eg, leg cellulitis), or presence of a prosthetic heart valve
• Fever: Elevated temperature is a sign of infection, which is a common finding in clients with IE.
• Nontender, erythematous, macular lesions on the palms or soles (Janeway lesions): Janeway lesions are
characteristic of IE. They occur when turbulent blood flow through the heart valves causes pieces of endocardial
vegetation to break off, forming microemboli that travel through the arteries to end-capillaries and block blood flow.
• Nonblanching, thin, red/dark longitudinal lines under the nail beds (splinter hemorrhages): Like Janeway lesions,
splinter hemorrhages are caused by microemboli that break off from vegetative lesions in the heart and travel through the
arteries to end-capillaries and block blood flow.
The client is admitted to the inpatient mental health unit. For each potential intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
- A. Assign the client to a shared room if available
- B. Avoid placing utensils on the client's meal tray
- C. Check on the client at frequent, irregular intervals
- D. Perform frequent room searches for harmful objects
- E. Perform mouth checks after medication administration
- F. Encourage the client to participate in grooming and hygiene
- G. Avoid discussion of suicidal thoughts when talking to the client
Correct Answer:
Rationale: Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include the
following:
• Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the
client
• Avoiding utensils on the client's meal tray that could be used for self-harm
• Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff
surveillance
• Performing frequent room searches for harmful objects to ensure client safety
• Performing mouth checks after medication administration to ensure the client has swallowed medication and is not
saving them for a future overdose attempt
• Encouraging the client to participate in grooming and hygiene because the client may exhibit loss of interest in daily
activities, decreased energy, and lack of motivation
Avoiding discussion of suicidal thoughts is not appropriate. Clients with suicidal ideation are often reluctant to disclose
their thoughts unless asked directly. The nurse should establish a nonjudgmental, therapeutic relationship that allows for open
communication.
It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the
restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the
restroom, to ensure safety.
The nurse has reviewed the information from the Prescriptions. The client received 2 L of lactated Ringer solution IV, 100 mg thiamine IV, and vitamin B, plus doxylamine IV shortly after arrival due to reports of severe nausea and vomiting. Click to highlight below the prescription that the nurse should anticipate completing next when planning care with the registered nurse.
- A. 10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
- B. 1000 mg calcium carbonate q6h
- C. 10 mL multivitamin and 0.6 mg folic acid once daily
- D. 12.5 mg promethazine q6h
Correct Answer: A
Rationale: Clients with hyperemesis gravidarum (HG) may require hospitalization if experiencing hypovolemia and electrolyte abnormalities. On
admission, clients with HG usually receive fluid replacement (eg, lactated Ringer solution) and antiemetics (eg, doxylamine and vitamin Bg).
Thiamine (vitamin B,) is often administered in initial fluids to prevent Wernicke encephalopathy.
For clients with HG experiencing hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) due to vomiting, it is critical to administer potassium
chloride promptly. Hypokalemia can have multiple potentially serious effects that, without intervention, put the client at immediate risk for
death; such effects include cardiac dyshythmia, respiratory muscle weakness causing respiratory failure, and impaired gastrointestinal
motility causing constipation and ileus