Nokea
The nurse cares for a client diagnosed with Addison disease. Which clinical finding would the nurse anticipate?
- A. Acanthosis nigricans
- B. Hirsutism
- C. Truncal obesity
- D. Weight loss
Correct Answer: D
Rationale: Addison disease causes weight loss (D) due to cortisol deficiency. Acanthosis nigricans (A), hirsutism (B), and truncal obesity (C) are associated with other endocrine disorders.
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A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, 'From now on, I'm going to store all medicines in my top dresser drawer.' Which is the best response by the nurse?
- A. Can you lock your dresser drawer?
- B. Make sure all of your medicines have childproof caps.
- C. That sounds like a safe plan.
- D. You need to keep an eye on your child at all times.
Correct Answer: A
Rationale: A locked drawer (A) ensures safety. Childproof caps (B) are helpful but insufficient alone. The plan (C) is unsafe without a lock, and constant supervision (D) is unrealistic.
The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to
- A. check the newborn's anus for muscle tone
- B. cover the area with a sterile, moist dressing
- C. measure the occipital frontal circumference
- D. place the newborn in the supine position
Correct Answer: B
Rationale: A myelomeningocele requires a sterile, moist dressing (B) to prevent infection and drying. Checking anus tone (A), measuring head circumference (C), and supine positioning (D) are secondary or contraindicated.
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
- A. Maintaining and preserving function
- B. Anticipating side effects of therapy
- C. Supporting coping with limitations
- D. Ensuring compliance with medications
Correct Answer: A
Rationale: Maintaining and preserving function. Preserving joint function is critical for quality of life in arthritis.
The nurse is caring for a child newly diagnosed with cystic fibrosis. What interventions does the nurse expect to be included in the client's multidisciplinary plan of care?
- A. Chest physiotherapy
- B. Genetic counseling
- C. Low-calorie diet
- D. Oral fluid restriction
- E. Spiritual support
Correct Answer: A,B,E
Rationale: Chest physiotherapy (A) clears mucus, genetic counseling (B) addresses hereditary aspects, and spiritual support (E) aids coping. A high-calorie diet, not low-calorie (C), is needed for nutrition. Fluid restriction (D) is inappropriate, as hydration is encouraged.
The nurse is talking with the parent of a 5-year-old client who is receiving morphine for pain. Which of the following statements by the parent would be a priority to follow up?
- A. My child may act aggressively when experiencing pain.
- B. I am concerned that my child thinks the pain is punishment.
- C. The FACES pain scale can be used to monitor my child's pain level.
- D. My child is playing and therefore does not need any pain medication now.
Correct Answer: D
Rationale: Assuming a playing child has no pain (D) is incorrect, as children may play despite pain. This requires follow-up to ensure adequate pain management. Aggression (A) and feeling punished (B) are valid concerns but less urgent. Using the FACES scale (C) is appropriate.