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During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order:
- A. Enzyme-linked immunosuppressant assay
- B. Stool for Clostridium difficile test
- C. Flat palate X-ray of the abdomen
- D. Electrolyte panel and hemogram
Correct Answer: B
Rationale: The client's symptoms of abdominal pain, fever, and "horse barn" smelling diarrhea are concerning for Clostridium difficile infection, especially in the setting of receiving chemotherapy which can weaken the immune system. Clostridium difficile is a bacteria that can cause severe diarrhea and inflammation of the colon. Testing for Clostridium difficile in the stool is crucial for diagnosing the infection and guiding appropriate treatment. Therefore, advising the physician to order a stool test for Clostridium difficile would be the most important in this scenario to confirm the diagnosis and initiate appropriate management.
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A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by rapidly progressive dyspnea, hypoxemia, and noncardiogenic pulmonary edema. The key signs of ARDS include severe respiratory distress, low partial pressure of oxygen (paO2), and bilateral infiltrates on chest x-ray. In the given scenario, the client presenting with restlessness and suprasternal retractions along with a paO2 level of 62 indicates severe respiratory distress and hypoxemia, which are consistent with ARDS. Therefore, option C is the most indicative of ARDS among the choices provided.
Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: When it comes to snake bites, one should not exercise the bitten extremity as it can increase the spread of venom in the body. Moving the affected limb can potentially lead to the venom spreading more quickly through the lymphatic system and into the bloodstream. Therefore, it is essential to keep the victim as calm and still as possible to minimize the effects of the venom. Proper first aid for snake bites includes keeping the victim calm, immobilizing the bitten limb, and seeking immediate medical attention.
Which should the nurse recommend to prevent urinary tract infections in young girls?
- A. Wear cotton underpants.
- B. Limit bathing as much as possible.
- C. Increase fluids; decrease salt intake.
- D. Cleanse perineum with water after voiding.
Correct Answer: A
Rationale: Cotton underpants are recommended to prevent urinary tract infections in young girls because they allow for better air circulation, which helps keep the genital area dry and reduces the likelihood of bacterial growth. Synthetic materials can trap moisture and create a warm and moist environment that promotes bacterial infections. Therefore, wearing cotton underpants is a simple and effective way to promote good hygiene and prevent urinary tract infections in young girls.
When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
- A. Depression
- B. Excessive sleepiness
- C. A history of cocaine use
- D. A preoccupation with death
Correct Answer: D
Rationale: A key indicator of high risk for suicide in a severely depressed adolescent is a preoccupation with death. This preoccupation may manifest as talking about death frequently, expressing a desire to die, or showing an interest in activities or media related to death. It is important for healthcare providers to take any mention of suicidal thoughts or intentions seriously and to assess for other risk factors. While depression, excessive sleepiness, and a history of cocaine use may also be concerning in an adolescent's mental health assessment, a preoccupation with death is a more direct indicator of suicidal risk. It is crucial for healthcare providers to address suicidal ideation promptly and to ensure the adolescent receives appropriate mental health support and interventions.