Nokea
For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
- A. Hypercapnia
- B. Muscle rigidity
- C. Tachycardia
- D. Urticaria
- E. Wheezes
Correct Answer:
Rationale: Rationales provided within the question context.
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Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
Which of the following findings should the nurse expect?
- A. Spotting
- B. Nausea
- C. Polyhydramnios
- D. Uterine tenderness
Correct Answer: A
Rationale: The correct answer is A: Spotting. Spotting is a common finding in early pregnancy due to implantation bleeding or hormonal changes. It is often a normal occurrence, especially in the first trimester. Nausea (choice B) is another common finding in early pregnancy, known as morning sickness. Polyhydramnios (choice C) is an excessive accumulation of amniotic fluid and is not typically an expected finding. Uterine tenderness (choice D) can be a sign of infection or other issues, not a typical finding in early pregnancy.
Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
- A. Increased blood pressure
- B. Weight Loss
- C. Decreased inflammation
- D. Decreased pain
Correct Answer: B
Rationale: The correct answer is B: Weight Loss. Furosemide is a loop diuretic that helps the body excrete excess fluid and sodium through increased urine output. Therefore, weight loss would indicate that the medication has been effective in reducing the client's fluid volume excess. Increased blood pressure (A) would not be an expected finding as furosemide typically helps lower blood pressure. Decreased inflammation (C) and decreased pain (D) are not directly related to the action of furosemide as a diuretic.
Which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. This finding indicates the newborn is experiencing withdrawal because it is a common symptom of withdrawal from substances such as opioids or benzodiazepines. Hypertonicity refers to increased muscle tone, which can be observed through increased resistance to passive movement. It is a sign of central nervous system hyperirritability, often seen in newborns going through withdrawal. Bulging fontanels (A) are a sign of increased intracranial pressure. Acrocyanosis (B) is a normal finding in newborns and is due to immature circulation. Bradycardia (C) is a slow heart rate, which can be caused by various factors in newborns, not specifically indicative of withdrawal.