Nokea
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
- A. Report the findings to the physician
- B. Assist the client to do range of motion exercises
- C. Check the client's potassium level
- D. Administer the as-needed dose of phenytoin (Dilantin)
Correct Answer: A
Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.
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The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
- A. A multigravida with diabetes mellitus
- B. A primigravida with preeclampsia
- C. A multigravida with preterm labor
- D. A primigravida with hyperemesis gravidarum
Correct Answer: B
Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Aplastic crisis
- B. Vaso-occlusive crisis
- C. Dactylitis crisis
- D. Sequestration crisis
Correct Answer: D
Rationale: Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
- A. New parents need time to learn how to hold the newborn.
- B. The umbilical cord needs time to separate.
- C. Newborn skin is easily traumatized by washing.
- D. The chance of chilling the newborn outweighs the benefits of bathing.
Correct Answer: B
Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.
The nurse is caring for a client with a diagnosis of placenta accreta. Which intervention is most appropriate?
- A. Prepare for possible hysterectomy
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. Administer antibiotics
Correct Answer: A
Rationale: Placenta accreta often prevents placental separation leading to severe hemorrhage during delivery which may necessitate hysterectomy. Tocolytics fetal monitoring and antibiotics are not primary interventions for this condition.
A home health nurse has several elderly clients in her case load. Which of the following clients ~(is most likely to be a victim of elder abuse?
- A. A 76-year-old female with Alzheimer's dementia
- B. A 70-year-old male with diabetes mellitus
- C. A 64-year-old female with a hip replacement
- D. A 72-year-old male with Parkinson's disease
Correct Answer: A
Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.