Nurse Jeremy is evaluating a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
- A. Fluid intake should be double the urine output.
- B. Fluid intake should be approximately equal to the urine output.
- C. Fluid intake should be half the urine output.
- D. Fluid intake should be inversely proportional to the urine output.
Correct Answer: B
Rationale: The principle of fluid balance in the body dictates that fluid intake should be approximately equal to the urine output, under normal circumstances. This balance ensures that the body maintains proper hydration levels and that the kidneys are functioning effectively in filtering and excreting waste products. Significant deviations between fluid intake and urine output can indicate potential issues with hydration status or kidney function, making it essential for healthcare professionals like Nurse Jeremy to closely monitor and evaluate these values.
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The nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: Hypoglycemia is defined as a blood glucose level below 70mg/dl. When a client is experiencing hypoglycemia, it means their blood sugar is lower than the normal range and can lead to symptoms such as sweating, tremors, confusion, and even loss of consciousness. It is important for nurses to recognize and treat hypoglycemia promptly to prevent serious complications.
Which are clinical manifestations of the postterm newborn? (Select all that apply.)
- A. Excessive lanugo
- B. Increased subcutaneous fat
- C. Absence of scalp hair
- D. Parchment-like skin
Correct Answer: D
Rationale: Postterm newborns are infants born after 42 weeks of gestation. Some common clinical manifestations of postterm newborns include parchment-like, wrinkled skin due to prolonged exposure to amniotic fluid, and long fingernails as a result of intrauterine growth beyond the expected term. Excessive lanugo and absence of scalp hair are not typically seen in postterm newborns. Increased subcutaneous fat may be more common in infants born at term or post-term, but it is not a specific clinical manifestation of postterm newborns. Minimal vernix caseosa is also usually present in postterm newborns.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
In neuroblastoma, metastatic spread can occur via local invasion or distant hematogenous/lymphatic routes. The LEAST common site of metastases in neuroblastoma is
- A. long bone
- B. bone marrow
- C. lung
- D. skin
Correct Answer: D
Rationale: Skin metastases are rare in neuroblastoma compared to bone, bone marrow, and lung involvement.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.