Nokea
Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid?
- A. Immobilizing the joint
- B. Lowering the injured area
- C. Applying cold to the area
- D. Applying pressure
Correct Answer: C
Rationale: Hemophilia is a condition where the blood fails to clot properly. Applying cold to the area can cause vasoconstriction (narrowing of blood vessels) which may slow down the blood flow and exacerbate the bleeding in individuals with hemophilia. Therefore, instructing Mr. and Mrs. Smith to avoid applying cold to the area of injury is crucial in order to prevent further complications.
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Which of the ff is a sign or symptom characteristic of the later stages of TB?
- A. Fatigue
- B. Anorexia
- C. Hemoptysis
- D. Weight loss
Correct Answer: C
Rationale: Hemoptysis, which refers to coughing up blood, is a sign characteristic of the later stages of tuberculosis (TB). This symptom occurs when there is significant damage to the lungs due to the progression of the disease. Hemoptysis in TB can indicate advanced disease and the presence of cavities in the lungs where blood vessels may become eroded. It is a serious symptom that often requires immediate medical attention. While fatigue, anorexia, and weight loss are common symptoms of TB, hemoptysis specifically points towards the later stages of the disease and severe lung involvement.
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
- A. Breast tenderness
- B. Increased facial hair
- C. Menstrual irregularities
- D. Hair loss
Correct Answer: C
Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic and aldosterone antagonist that is commonly used to treat conditions such as hypertension, heart failure, and edema. One of its common side effects is hormonal effects due to its antiandrogenic properties. In women, spironolactone can lead to menstrual irregularities, including amenorrhea (absence of menstrual periods) or breakthrough bleeding. Therefore, in a client who has had a unilateral adrenalectomy (removal of one adrenal gland), which can already disrupt hormonal balance, the nurse should educate the client about the potential for menstrual irregularities when taking spironolactone.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: A
Rationale: Toni's response of minimizing her visual problems, talking about pursuing advanced degrees, asking about full-time job opportunities in nursing, and mentioning her desire to have more children despite her current health situation may suggest inappropriate euphoria characteristic of the disease process. Inappropriate euphoria can be a sign of an altered mental state that is not in line with the reality of the situation. It is important for healthcare providers to recognize such emotional responses as they may indicate underlying mental health issues or the need for further assessment and support.
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.