Nokea
The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
- A. Have you noticed a change in sleeping habits recently?
- B. Have you had a respiratory infection in the last 6 months?
- C. Have you lost weight recently?
- D. Have you noticed changes in your alertness?
Correct Answer: C
Rationale: Unexplained weight loss is a common symptom of leukemia due to increased metabolic demand and systemic effects of the disease.
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The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: Cushing's disease causes immunosuppression, increasing infection risk, warranting a private room.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
- A. A 6-month-old
- B. A 4-year-old
- C. A 12-year-old
- D. A 13-year-old
Correct Answer: B
Rationale: A 4-year-old is at greatest risk due to their curiosity, mobility, and tendency to explore their environment, often putting objects in their mouths.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.