Nokea
The community health nurse has reviewed information about the population of a local community and has determined that there are groups in the population that are at high risk for infection with tuberculosis (TB). The nurse targets which high-risk group for screening?
- A. French Canadians
- B. White, Anglo-Saxon Americans
- C. Older clients in long-term-care facilities
- D. Adolescents between the ages of 13 and 17 years
Correct Answer: C
Rationale: Older clients in long-term-care facilities are at high risk for TB due to age-related immune decline and close living conditions. French Canadians, White Anglo-Saxon Americans, and adolescents are not specifically high-risk groups unless other factors apply.
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The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?
- A. I will report any feeling of pelvic pressure.
- B. I will not engage in sexual intercourse at this time.
- C. I will adhere to the limitations in activity and stay off my feet.
- D. I will limit my fluid intake to three 8-ounce glasses of fluid per day.
Correct Answer: D
Rationale: Risks for preterm labor include dehydration. A client should not restrict fluids (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure without the perception of a contraction. Mechanical stimulation of the cervix during intercourse can stimulate contractions. A decrease in activity and bed rest are often prescribed in an attempt to decrease pressure on the cervix and to increase uterine blood flow.
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.
A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
- A. People who develop mental illnesses often had a very traumatic childhood experience.
- B. There is some evidence that contracting a virus during childhood can lead to mental disorders.
- C. Sometimes people with mental illness have an overactive immune system.
- D. We don't fully understand the cause, but mental illnesses do seem to run in the family.
Correct Answer: D
Rationale: The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders. Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.
The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?
- A. Because of this dysrhythmia, blood backs up in the legs and puts you at risk for blood clots.
- B. This dysrhythmia decreases the volume of blood flowing from the heart, which can lead to blood clots forming in the brain.
- C. The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this medication to prevent them.
- D. Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which could then loosen and travel to the lungs or brain.
Correct Answer: D
Rationale: In atrial fibrillation, the quivering atria cause sluggish blood flow, leading to clot formation along the heart wall, which can dislodge and cause pulmonary or cerebral emboli. Options A, B, and C inaccurately describe the mechanism requiring anticoagulation.
Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?
- A. Type 1 diabetes occurs due to increased carbohydrate intake and lack of exercise
- B. Type 1 diabetes is managed through diet and exercise
- C. Type 1 diabetes is caused by destruction of beta cells in the pancreas
- D. Type 1 diabetes leads to the body's cells rejecting insulin
Correct Answer: C
Rationale: Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy. Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits. Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.