Nokea
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.
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A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To reduce fear of the unknown
- B. To keep the child calm
- C. To establish a trusting relationship
- D. To prevent or minimize separation anxiety
Correct Answer: D
Rationale: Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.
The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
- A. Fetal bleeding
- B. Maternal hemorrhage
- C. Preterm labor
- D. Fetal macrosomia
Correct Answer: A
Rationale: Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Tilt her head backwards
- B. Swallow as tube passes
- C. Hold breath as tube passes
- D. Cough as tube passes
Correct Answer: B
Rationale: Swallowing assists with insertion of tube and closes off airway.
A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.
A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
- A. Hyperammonemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.