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Hirschprung's Disease is somewhat similar to cystic fibrosis. In both diseases, the newborn does not pass out meconium.
Pathophysiologically, in Hirschprung's Disease, the child's affected organ is:
- A. Small intestine
- B. Large intestine
- C. Stomach
- D. Liver
Correct Answer: B
Rationale: Hirschprung's disease involves aganglionic segments of the large intestine, causing obstruction.
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For a client with Graves' disease, which nursing intervention promotes comfort?
- A. Restricting intake of oral fluids
- B. Placing extra blankets on the client's bed
- C. Limiting intake of high-carbohydrate foods
- D. Maintaining room temperature in the low-normal range
Correct Answer: D
Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Check the client's level of consciousness
- B. Obtain the regular blood glucose readings
- C. Determine if special skin care is needed
- D. Answer questions from the client's spouse about the plan of care
Correct Answer: B
Rationale: The UAP can safely obtain blood glucose readings, which are routine tasks.
A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?
- A. Mild edema in the lower extremities
- B. Heartburn
- C. Severe headache and visual disturbances
- D. Frequent urination
Correct Answer: C
Rationale: Severe headache and visual disturbances suggest preeclampsia, a medical emergency. Mild edema, heartburn, and frequent urination are normal in late pregnancy.
The physician orders high protein, high calorie and high salt diet on Valerie.
When ask by the patient, the nurse would explain that
- A. high salt diet replaces potassium loss in the urine.
- B. high protein, high calorie diet is needed for tissue repair and energy expenditure.
- C. high protein and high calorie diet is important in gaining weight.
- D. extra salt is needed to increase the low sodium level in Addison's disease.
Correct Answer: D
Rationale: Lack of mineralcorticoids (aldosterone) leads to a loss of sodium ions in the urine and subsequent hyponatremia, necessitating a high salt diet.
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.