Nokea
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
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Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
Which of the following statements about nasoenteric tubes is correct?
- A. The tube cannot be attached to suction.
- B. The tube contains a soft rubber bag filled with mercury.
- C. The tube is taped securely to the client's cheek after insertion.
- D. The tube can have its placement determined only by auscultation.
Correct Answer: C
Rationale: Nasoenteric tubes are taped securely to the client's cheek to prevent dislodgement. They can be attached to suction, do not typically use mercury today, and placement is confirmed by methods like X-ray, not just auscultation. CN: Physiological adaptation; CL: Apply
A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?
- A. Zyban (Bupropion)
- B. Nicotine (Nicotrol)
- C. Nitroglycerin (Tridil)
- D. Ibuprofen (Advil)
Correct Answer: A
Rationale: Zyban (bupropion) is an antidepressant that reduces nicotine cravings and withdrawal symptoms, making it effective for smoking cessation in Buerger's disease. Nicotine replacement (Nicotrol) may help but continues nicotine exposure, nitroglycerin is for angina, and ibuprofen is irrelevant.
Which of the following complications is associated with mechanical ventilation?
- A. Gastrointestinal hemorrhage.
- B. Immunosuppression.
- C. Increased cardiac output.
- D. Pulmonary emboli.
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.