Nokea
The home health nurse is visiting a 30-year-old with sickle cell disease. Assessment findings include spleenomegaly. What information obtained on the visit would cause the most concern? The client:
- A. Eats fast food daily for lunch
- B. Drinks a beer occasionally
- C. Sometimes feels fatigued
- D. Works as a furniture mover
Correct Answer: D
Rationale: Working as a furniture mover involves heavy physical exertion, which can trigger a sickle cell crisis due to increased oxygen demand and dehydration, posing a significant risk.
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The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintaining the client's systolic blood pressure at 70 mmHg or greater
- B. Maintaining the client's urinary output greater than 300 cc per hour
- C. Maintaining the client's body temperature of greater than 33°F rectal
- D. Maintaining the client's hematocrit at less than 30%
Correct Answer: A
Rationale: Adequate blood pressure ensures organ perfusion for donation.
A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
- A. Slow pulse rate, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respirations
Correct Answer: B
Rationale: Myxedema (severe hypothyroidism) presents with weight gain, lethargy, slowed speech, and decreased respiratory rate due to metabolic slowing.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
- A. Mild nausea.
- B. Hot flashes.
- C. Vaginal bleeding.
- D. Hair thinning.
Correct Answer: C
Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer
The nurse is conducting an aphasia assessment of a client who has suffered a stroke. Which of the following observations should the nurse include in the assessment? Select all that apply.
- A. Spontaneous speech.
- B. Comprehension of the spoken and written word.
- C. Ability to name objects.
- D. Ability to describe objects.
- E. Ability to write.
- F. Ability to recall four named items after five minutes.
Correct Answer: A,B,C,D,E
Rationale: Aphasia assessment post-stroke includes evaluating spontaneous speech (A), comprehension (B), naming objects (C), describing objects (D), and writing (E). Memory recall (F) is not specific to aphasia.
The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq. The nurse should administer the medication:
- A. Slow, continuous IV push over 10 minutes
- B. Continuous infusion over 30 minutes
- C. Controlled infusion over 5 hours
- D. Continuous infusion over 24 hours
Correct Answer: C
Rationale: Potassium chloride should be administered slowly (e.g., over 5 hours for 50 mEq) to prevent cardiac complications, as rapid infusion can cause hyperkalemia.