Nokea
The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Contact precautions
- C. Droplet precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.
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A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.
The nurse is caring for a client with B-thalassemia major. Which therapy is used to treat B-thalassemia major?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: B-thalassemia major causes severe anemia due to defective hemoglobin synthesis, requiring frequent blood transfusions to maintain hemoglobin levels. IV fluids, oxygen, and iron therapy (which can cause overload) are not primary treatments.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which recommendation is most appropriate?
- A. Limit exercise to once a week.
- B. Reduce sodium intake.
- C. Increase caffeine consumption.
- D. Avoid stress management techniques.
Correct Answer: B
Rationale: Reducing sodium intake lowers blood pressure in hypertension by decreasing fluid retention. Exercise should be regular, caffeine avoided, and stress management encouraged.
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Actual injury related to poor impulse control by the father
- C. Ineffective coping
- D. Altered family process related to physical abuse
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. Would you describe the intensity, duration, and symptoms associated with your pain?
- B. Do you experience swelling at the end of the day in the affected and unaffected leg?
- C. Have you had any lesions of the affected leg that have been difficult to heal?
- D. Do your muscle spasms occur following rest, walking, or exercising?
Correct Answer: D
Rationale: Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.