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For a client in addisonian crisis, it would be very risky for a nurse to administer:
- A. potassium chloride.
- B. hydrocortisone.
- C. normal saline solution
- D. fludrocortisone.
Correct Answer: A
Rationale: Addisonian crisis, also known as acute adrenal crisis, is a life-threatening condition that occurs when there is a severe deficiency in cortisol and aldosterone hormones, usually resulting from adrenal gland insufficiency. In this situation, it is crucial to administer hydrocortisone (a synthetic form of cortisol) promptly to replace the lacking hormone. Potassium levels in individuals experiencing an Addisonian crisis can be elevated due to the lack of aldosterone, which normally helps regulate electrolyte levels such as potassium. Therefore, administering potassium chloride in this scenario can lead to further complications and exacerbate the existing electrolyte imbalance. In contrast, normal saline solution can help with fluid and electrolyte balance, and fludrocortisone can be administered to replace the deficient aldosterone.
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The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. What is the rationale for this position?
- A. It prevents cremasteric reflex.
- B. Undescended testes can be palpated.
- C. This tests the child for an inguinal hernia.
- D. The child does not yet have a need for privacy.
Correct Answer: A
Rationale: The "tailor" position, also known as the frog-leg position, is used during palpation for the testes in young boys because it helps prevent the cremasteric reflex. The cremasteric reflex is a normal reflex in which the testes are pulled upwards towards the inguinal canal when the inner thigh is stroked. By having the child sit in the tailor position, with the knees pulled up and legs rotated outwards, the reflex is less likely to be elicited, allowing for a more accurate examination of the testes.
Potential sources of mercury include all of the following EXCEPT
- A. swordfish
- B. old teething powders
- C. quicksilver
- D. milk
Correct Answer: D
Rationale: Mercury is not typically found in milk. It is commonly found in fish, old teething powders, quicksilver, and other sources.
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
- A. "The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!"
- B. "His stroke has made him less inhibited. We'll see if we can find a male assistant to help him."
- C. "We have to take care of all patients equally, even the dirty old men."
- D. "He didn't mean anything by it, just ignore it."
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: B
Rationale: The outcome that indicates successful fluid resuscitation in managing diarrhea is when the patient reports a decrease in stool frequency and liquidity. This is because diarrhea is characterized by an increase in stool frequency and liquidity due to the body's attempt to expel irritants or infections. By successfully resuscitating with fluids, the goal is to rehydrate the body and restore electrolyte balance, which should lead to a decrease in stool frequency and formation of more solid stools. This improvement in stool consistency and frequency is a clear indicator that the fluid resuscitation has been effective in treating the diarrhea. Therefore, option B is the correct choice for the outcome indicating successful fluid resuscitation in this scenario.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multiple organs in the body, including the lungs. Patients with SLE are at risk for developing various respiratory complications, which can result in abnormal lung sounds on auscultation. Common respiratory manifestations of SLE include pleurisy, pleural effusion, interstitial lung disease, and pulmonary hypertension. Therefore, the nurse assessing Mrs. Diwa can expect to find abnormal lung sounds indicative of these respiratory complications. However, it is important to note that SLE can also present with a wide range of other symptoms affecting different organ systems.