Nokea
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
- A. Measure the client’s oral temperature.
- B. Ask a colleague for assistance.
- C. Give the client a clean gown and warm blankets.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: Step 1: Assess the client's vital signs to confirm presence of fever.
Step 2: Measure client's oral temperature to obtain accurate reading.
Step 3: Document temperature and report findings to healthcare provider.
Step 4: Initiate appropriate interventions based on temperature reading.
Step 5: Reassess client's condition to evaluate effectiveness of interventions.
Summary: Option A is correct as it directly addresses the cue of fever by confirming the temperature. Options B, C, and D are incorrect as they do not directly address the need to assess the client's temperature for accurate evaluation and intervention.
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A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term.
Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues.
Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels.
Step 4: Emergency numbers are important but secondary to long-term management.
Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.
Which of the following is an appropriate nursing intervention to prevent infection in patients with AIDS?
- A. Prohibiting patients who are severely immunodeficient from having any visitors.
- B. Prohibiting visitors with a cough.
- C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room.
- D. Ensuring protective barrier isolation precautions are in place.
Correct Answer: C
Rationale: The correct answer is C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room is crucial to prevent infection in patients with AIDS. This intervention helps to minimize the risk of transmitting pathogens to the patient and vice versa. The protective gear acts as a barrier to prevent the spread of infectious agents. It also protects healthcare workers from exposure to potentially harmful pathogens.
Prohibiting visitors who are severely immunodeficient (choice A) may be isolating for the patient and does not directly address preventing infection transmission. Prohibiting visitors with a cough (choice B) is important but does not cover all potential sources of infection. Ensuring protective barrier isolation precautions are in place (choice D) is a general statement and does not specify the practical steps needed to prevent infection transmission effectively.
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: B
Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL
- B. Blood pressure of 90/50mmHg
- C. Pulse rate of 126 beats/min
- D. Urine output of more than 200mL/hour
Correct Answer: A
Rationale: The correct answer is A: Fluid intake of less than 2,500mL. In diabetes insipidus, the body cannot properly regulate fluid balance, leading to excessive thirst and urination. Successful treatment aims to manage these symptoms by reducing fluid intake to prevent dehydration. Therefore, a decrease in fluid intake indicates successful treatment.
Explanation for incorrect choices:
B: Blood pressure of 90/50mmHg - Blood pressure is not directly related to the treatment of diabetes insipidus.
C: Pulse rate of 126 beats/min - Pulse rate is not a specific indicator of successful treatment for diabetes insipidus.
D: Urine output of more than 200mL/hour - In diabetes insipidus, excessive urine output is a symptom of the condition, so an increase in urine output does not indicate successful treatment.