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In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
- A. Moist lips
- B. Pink conjunctivae
- C. Spoon-shaped nails
- D. Not easily plucked hair
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia).
Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency.
Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment.
Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
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A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
- A. gastrointestinal upset.
- B. effects of magnesium sulfate.
- C. anxiety caused by hospitalization.
- D. worsening disease and impending convulsion.
Correct Answer: D
Rationale: The correct answer is D because the patient's symptoms of pounding headache, visual changes, and epigastric pain are classic signs of worsening preeclampsia, indicating a significant increase in blood pressure and potential progression to eclampsia (seizures). Immediate medical intervention is crucial to prevent complications.
A: Gastrointestinal upset does not explain the combination of symptoms presented.
B: Magnesium sulfate is used to prevent seizures in preeclampsia but does not cause these specific symptoms.
C: Anxiety does not typically present with the specific physical symptoms mentioned.
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?
- A. The need to begin immunotherapy as soon as possible
- B. The need for the parents to carry an epinephrine pen
- C. The need to vigilantly maintain the childs immunization status
- D. The need for the child to avoid all foods that have a high potential for allergies
Correct Answer: B
Rationale: The correct answer is B: The need for the parents to carry an epinephrine pen. This is the priority for health education because in case of another anaphylactic reaction to walnuts, immediate administration of epinephrine can be life-saving. Immunotherapy (choice A) is not the primary focus in an emergency situation. Maintaining immunization status (choice C) is important but not as critical as having an epinephrine pen. Avoiding high potential allergens (choice D) is important but having an epinephrine pen takes precedence in managing severe allergic reactions.
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
- A. Serum albumin level
- B. Weight history
- C. White blood cell count
- D. Body mass index E) Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.
A nurse who sits on the hospitals ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide?
- A. Administering a lethal dose of medication to a patient whose death is imminent
- B. Administering a morphine infusion without assessing for respiratory depression
- C. Granting a patients request not to initiate enteral feeding when the patient is unable to eat
- D. Neglecting to resuscitate a patient with a do not resuscitate order
Correct Answer: A
Rationale: The correct answer is A because administering a lethal dose of medication to a patient whose death is imminent directly causes the patient's death, constituting assisted suicide. This action is intentional and aims to end the patient's life. In contrast, choices B, C, and D do not involve intentionally causing the patient's death. Choice B involves a medication error but not with the intent to end the patient's life. Choice C respects the patient's autonomy in refusing treatment. Choice D honors the patient's wishes for end-of-life care. Thus, only choice A aligns with the definition of assisted suicide.
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
- A. Stool softeners are contraindicated.
- B. Laxatives should be taken daily.
- C. Consume 2 to 4 L of fluid daily.
- D. Restrict calcium intake.
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.