The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.
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A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.
A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?
- A. I feel so exhausted that I started taking naps when the baby sleeps.
- B. I have trouble sleeping well at night because I worry that I won't hear the baby cry.
- C. My aunt has come over every day to care for the baby because the baby's cries bother me.
- D. My spouse thinks that I have been more emotional since I had the baby last week.
Correct Answer: C
Rationale: Being bothered by the baby's cries (C) may indicate postpartum depression, requiring investigation. Exhaustion (A), worry (B), and emotionality (D) are common postpartum experiences.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
- C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct Answer: A
Rationale: To elicit the biceps reflex, the nurse places her thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer, so A is correct. Answer B is incorrect as it describes a different technique. Answer C refers to the patellar reflex, and Answer D is not a standard method for the biceps reflex.
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
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