Nokea
The nurse has completed teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which item(s) on a daily basis?
- A. Activity
- B. Pulse and respiratory rate
- C. Intake, output, and weight
- D. Blood urea nitrogen and creatinine levels
Correct Answer: C
Rationale: Recording daily intake, output, and weight helps monitor fluid status, ensuring no more than 0.5 kg weight gain per day between hemodialysis sessions. Activity, pulse, respiratory rate, and lab values are not daily client responsibilities.
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A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
- A. Massaging the reddened areas
- B. Performing range of motion exercises
- C. Administering antithrombotics as ordered
- D. Feeding the client a high-carbohydrate diet
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures that will prevent an alteration in skin integrity. Which statement by the mother indicates that teaching was effective?
- A. I need to place white gloves on my child's hands at night.
- B. I will apply generous amounts of a cortisone cream to prevent itching.
- C. I will give my child a glass of warm milk at bedtime to help my child sleep.
- D. I need to keep my child in a warm room at night so that the covers will not cause my child to scratch.
Correct Answer: A
Rationale: Placing white gloves on the child's hands at night prevents scratching during sleep, which helps maintain skin integrity and reduces the risk of secondary infections. Applying cortisone cream is not recommended without a prescription, as it may not be appropriate for chickenpox and could increase the risk of complications. Warm milk may help with sleep but does not directly address scratching or skin integrity. Keeping the child in a warm room does not prevent scratching and may increase discomfort, as cooler environments are often better for reducing itching.
A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.
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.
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.