Nokea
Phenylketonuria (PKU) is a genetic disease that results in the body's inability to correctly metabolize:
- A. glucose.
- B. phenylalanine.
- C. phenylketones.
- D. thyroxine.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder that affects the body's ability to metabolize the amino acid phenylalanine. Individuals with PKU lack an enzyme called phenylalanine hydroxylase, which results in the buildup of phenylalanine in the body. If untreated, high levels of phenylalanine can lead to intellectual disabilities, seizures, and other serious health problems. Therefore, individuals with PKU need to follow a special diet low in phenylalanine to prevent these complications.
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An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
Patient S is a sexually active adolescent; which of the following instructions would be included in the preventive teaching plan about urinary tract infections?
- A. Drinking acidic juices
- B. Avoiding urinating before intercourse
- C. Wearing nylon underwear
- D. Wiping back to front
Correct Answer: A
Rationale: Drinking acidic juices, such as cranberry juice, can help make the urine more acidic, which can potentially prevent bacteria from sticking to the urinary tract walls and reduce the risk of urinary tract infections. It is important to note that while acidic juices can be beneficial in some cases, they should not be relied upon as the sole preventive measure for UTIs. Other important preventive measures include staying hydrated, practicing good hygiene, and urinating before and after intercourse.
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
- A. Unequal growth of fingers and toes.
- B. Purplish discoloration of hands and feet.
- C. Webbing between fingers and toes.
- D. Deformities of the wrists and ankles.
Correct Answer: B
Rationale: Hand-foot syndrome, also known as dactylitis, is a common manifestation of sickle cell anemia. It is characterized by painful swelling and inflammation of the hands and feet, often resulting in a purplish discoloration due to decreased blood flow and oxygen delivery to the affected areas. This condition typically affects the soft tissues and joints of the hands and feet, leading to pain, swelling, and limited mobility. Unequal growth of fingers and toes, webbing between fingers and toes, and deformities of the wrists and ankles are not typically associated with hand-foot syndrome in sickle cell anemia.
The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
- A. Encourage the client to ask questions about personality sexuality
- B. Provide time for privacy
- C. Provide support for the spouse or significant other
- D. Suggest referral to a sex counselor or other appropriate professional
Correct Answer: D
Rationale: Suggesting a referral to a sex counselor or other appropriate professional would be the most appropriate intervention in this case. Impotence or erectile dysfunction can have significant emotional and psychological implications, especially in the context of a marital relationship. A sex counselor or therapist who specializes in sexual health can provide the necessary support, guidance, and strategies to help the client and his spouse navigate this issue effectively. This intervention is aimed at addressing the client's concerns about impotence, its impact on his marriage, and ultimately promoting holistic well-being.