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The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct Answer: B
Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.
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What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?
- A. Asterixis.
- B. Jaundice.
- C. Ascites.
- D. Splenomegaly.
Correct Answer: A
Rationale: The correct answer is A: Asterixis. Hepatic encephalopathy is a neuropsychiatric syndrome associated with liver dysfunction. Asterixis, also known as liver flap, is a key clinical manifestation characterized by a flapping tremor of the hands when extended. This occurs due to impaired ammonia metabolism in the liver leading to neurotoxicity. Jaundice (B) is a sign of liver dysfunction but not specific to hepatic encephalopathy. Ascites (C) is the accumulation of fluid in the peritoneal cavity, common in liver cirrhosis but not indicative of hepatic encephalopathy. Splenomegaly (D) is enlargement of the spleen, which can occur in cirrhosis but is not a direct sign of hepatic encephalopathy.
The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.
A healthcare professional is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information?
- A. Disease registry.
- B. Department of Health.
- C. Bureau of Vital Statistics.
- D. Census data.
Correct Answer: C
Rationale: The correct answer is C: Bureau of Vital Statistics. The Bureau of Vital Statistics is responsible for maintaining records on births, deaths, and other vital events in a particular region. Therefore, it is the most likely state resource to provide information on infant death rates. Disease registry (A) typically focuses on specific diseases rather than overall mortality rates. Department of Health (B) may have some data but may not specifically focus on vital statistics. Census data (D) provides population demographics but does not specifically track infant death rates.
What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Soft, spongy fundus.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 BPM.
- D. Unilateral lower leg pain.
Correct Answer: C
Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult.
A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony.
B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage.
D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.