Nokea
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multiple organs in the body, including the lungs. Patients with SLE are at risk for developing various respiratory complications, which can result in abnormal lung sounds on auscultation. Common respiratory manifestations of SLE include pleurisy, pleural effusion, interstitial lung disease, and pulmonary hypertension. Therefore, the nurse assessing Mrs. Diwa can expect to find abnormal lung sounds indicative of these respiratory complications. However, it is important to note that SLE can also present with a wide range of other symptoms affecting different organ systems.
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What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: A
Rationale: When caring for a client after heart transplantation, the signs of organ rejection that a nurse should closely monitor for include low white blood cell count and dyspnea.
Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: Canned tomato juice is often high in sodium content due to added salt during processing. Since Mr. Aurelio has been prescribed a 2 gm sodium diet, the nurse would instruct him to restrict foods high in sodium content, such as canned tomato juice. Whole wheat bread and apples are generally low in sodium, and beef tenderloin strips can be chosen in lean cuts and prepared without high sodium additives, making them more suitable for Mr. Aurelio's dietary restrictions.
Which of the ff is a sign or symptom of asthma?
- A. Production of abnormally thick, sticky mucus in lungs
- B. Faulty transport of sodium in lung cells
- C. Paroxysms or shortness of breath
- D. Altered electrolyte balance in the sweat glands
Correct Answer: C
Rationale: Paroxysms, or sudden attacks, of shortness of breath are a common sign or symptom of asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, which leads to difficulty breathing. During an asthma attack, individuals may experience sudden and severe shortness of breath, often accompanied by wheezing, coughing, and chest tightness. These paroxysms of breathlessness are a hallmark feature of asthma and indicate the presence of airway inflammation and constriction.
To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: C
Rationale: After thoracentesis, it is important to position the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. Placing the client on the unaffected side helps to promote proper drainage and reduce the risk of complications such as pneumothorax or fluid leakage. This position also allows for adequate lung expansion and facilitates proper re-expansion of the lung on the side where the fluid was removed. It is essential to follow this positioning to optimize outcomes and minimize risks associated with the procedure.
A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.