Nokea
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.
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For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
- A. Administering aspirin if the temperature exceeds 102â—‹1 F (38.8â—‹0 C)
- B. inspecting the skin for petechiae once every shift
- C. providing for frequent rest periods
- D. Placing the client in strict isolation
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
- A. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein
- B. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein
- C. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein
- D. 55% to 60% carbohydrate, 30% fat and 10% to 15% protein
Correct Answer: A
Rationale: In managing diabetes mellitus, one of the key principles is proper macronutrient distribution in the diet. The recommended dietary intake for a diabetic client typically includes a moderate amount of carbohydrates (30% to 35% of total calories) in order to help control blood sugar levels. Including higher amounts of fat (around 40%) can be beneficial in managing this condition as well. Adequate protein intake (25% to 30%) is also important for overall health and satiety. This balanced macronutrient distribution helps in maintaining stable blood sugar levels throughout the day, supporting optimal diabetes management.
You asked to obtain a measurement of serum sodium level in the hospital lab; you obtain a value of 125 mmol/L by repeating the test 5 times. The reference value of serum sodium at that lab is between 135-155 mmol/L. Your measurement is termed
- A. accurate but not precise
- B. precise but not accurate
- C. neither accurate nor precise
- D. both accurate and precise
Correct Answer: C
Rationale: The measurement is consistently low, indicating it is neither close to the true value (inaccurate) nor consistent with the reference range.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: When initiating IV therapy, the basilic vein is often used first due to its accessibility and size. The basilic vein is a common choice for venipuncture because it is located on the medial aspect of the arm and tends to be easily palpable. Additionally, the basilic vein is also less prone to complications such as nerve damage compared to other deeper veins like the jugular or brachiocephalic veins. Therefore, utilizing the basilic vein as the initial site for IV therapy is a safe and efficient choice.
A first-time mother brings in her 5-day-old baby for a well-child visit. The baby weighs 7 lb 5 oz, down from 7 lb 10 oz at discharge. The nurse's best response is:
- A. I will notify the doctor about this weight loss.
- B. Newborns can lose up to 10% of their birth weight and regain it by 2 weeks of age.
- C. I can tell you are a first-time mother; don't worry.
- D. Maybe the baby isn't getting enough milk. How often are you feeding?
Correct Answer: B
Rationale: A small weight loss is normal in the first week of life; infants typically regain their birth weight by 2 weeks.