Nokea
The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate?
- A. An excess of red blood cells
- B. An excess of white blood cells
- C. A deficiency of clotting factor VIII
- D. A deficiency of clotting factors VIII and IX
Correct Answer: C
Rationale: The correct answer is C: A deficiency of clotting factor VIII. Hemophilia A is characterized by a lack of clotting factor VIII, which is crucial for blood clotting. This deficiency results in prolonged bleeding. Choices A, B, and D are incorrect. There is no association between Hemophilia A and an excess of red blood cells (Choice A) or an excess of white blood cells (Choice B). Additionally, Hemophilia A specifically involves a deficiency of clotting factor VIII, not both factors VIII and IX (Choice D).
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The nurse is teaching a 27-year-old client with asthma about the management of their therapeutic regimen. Which statement would indicate the need for additional instruction?
- A. ''I should monitor my peak flow every day.''
- B. ''I should contact the clinic if I am using my medication more often.''
- C. ''I need to limit my exercise, especially activities such as walking and running.''
- D. ''I should learn stress reduction and relaxation techniques.''
Correct Answer: C
Rationale: Exercise, especially aerobic activities, is beneficial for clients with asthma as long as it is well-managed. Limiting exercise is not generally recommended unless specifically advised by a healthcare provider, indicating a need for further instruction in this case. Monitoring peak flow, contacting the clinic for increased medication use, and learning stress reduction techniques are all appropriate self-management strategies for asthma, indicating good understanding by the client.
A client with diabetes mellitus is receiving insulin glargine (Lantus). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hypertension
- D. Hypercalcemia
Correct Answer: A
Rationale: Insulin glargine is a long-acting insulin used to control blood sugar levels in diabetes. The nurse should monitor the client for hypoglycemia, which is a potential side effect of insulin therapy. Hypoglycemia occurs when blood sugar levels drop too low, leading to symptoms such as shakiness, dizziness, sweating, confusion, and in severe cases, loss of consciousness. Hyperkalemia (choice B) is an elevated potassium level, not typically associated with insulin glargine. Hypertension (choice C) is high blood pressure, which is not a common side effect of insulin glargine. Hypercalcemia (choice D) is an elevated calcium level and is not related to the use of insulin glargine.
When teaching a responsible family member how to perform a certain procedure for the patient, what is the best approach?
- A. Perform all these steps
- B. Arrange for the practice of the procedure
- C. Describe the procedure
- D. Demonstrate the procedure
Correct Answer: D
Rationale: The best approach when teaching a responsible family member a procedure for the patient is to demonstrate the procedure. By demonstrating, the family member can visually see how it is done, making it easier for them to understand and replicate. This hands-on approach is more effective than just describing the procedure (choice C) or arranging for practice (choice B) without a visual demonstration. Performing all the steps (choice A) may not be practical or necessary when the goal is to teach someone else how to do it.
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks, 'When can the tube be used for feeding?' The nurse's best response would be which of these comments?
- A. "Feedings can begin in 5 to 7 days."
- B. "The use of the feeding tube can begin immediately."
- C. "The stomach contents and air must be drained first."
- D. "The incision healing must be complete before feeding."
Correct Answer: C
Rationale: The correct answer is C: 'The stomach contents and air must be drained first.' Before starting feedings through a gastrostomy tube, it is essential to drain the stomach contents and air. This process helps prevent complications and ensures the proper functioning of the tube after placement. Choice A is incorrect because initiating feedings within 5 to 7 days may lead to complications if the stomach is not adequately prepared. Choice B is incorrect as feeding should not begin immediately to allow for proper preparation of the tube and the stomach. Choice D is incorrect because although incision healing is important, draining the stomach contents and air is a more immediate concern to prevent complications.
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
- A. Central nervous system damage
- B. Moderate anemia
- C. Renal tubule damage
- D. Growth impairment
Correct Answer: A
Rationale: Corrected Rationale: Chronic lead poisoning can lead to severe and irreversible damage to the central nervous system, including cognitive and developmental delays. Central nervous system damage is the most serious effect of chronic lead poisoning because it can have long-lasting consequences on a child's cognitive function and overall development. Moderate anemia (Choice B), renal tubule damage (Choice C), and growth impairment (Choice D) can also occur due to lead poisoning, but they are not as severe or potentially irreversible as the damage to the central nervous system.