Nokea
The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?
- A. Polyuria
- B. Cardiac dysrhythmias
- C. Dry mucous membranes
- D. Prolonged bleeding time
Correct Answer: B
Rationale: The inadequate production of aldosterone in clients with Addison's disease causes the inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Based on this information, none of the remaining options are manifestations that are associated with Addison's disease or hyperkalemia.
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A child is admitted to the hospital with a suspected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?
- A. Hematuria
- B. Presence of hematomas
- C. Presence of hemarthrosis
- D. Bleeding from the mucous membranes
Correct Answer: D
Rationale: The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike what is seen in clients with hemophilia, deep bleeding into joints and muscles is rare. Options 1, 2, and 3 are characteristic of those signs found in clients with hemophilia.
The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply.
- A. Temporary aphasia
- B. Throbbing headaches
- C. Transient hemiplegia
- D. Paresthesias of the hands and feet
- E. Unexplained loss of consciousness
Correct Answer: A,C,D
Rationale: Cerebral thrombosis does not occur suddenly. During the few hours or days before a thrombotic stroke, the client may experience a transient loss of speech (aphasia), hemiplegia, or paresthesias on one side of the body. Other signs and symptoms of thrombotic stroke vary, but they may include dizziness, cognitive changes, or seizures. Headache is rare, and a loss of consciousness is not likely to occur.
An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?
- A. Do you have a history of a recent brain abscess?
- B. Do you have a chronic hearing problem in the left ear?
- C. Do you successfully obtain pain relief with acetaminophen?
- D. Do you have a history of a recent upper respiratory infection (URI)?
Correct Answer: D
Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated.
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
- A. Fetal heart rate
- B. Maternal heart rate
- C. Fetal scalp sampling
- D. Maternal blood pressure
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.
When assessing a child which finding would indicate the presence of Kernig's sign?
- A. Calf pain when the foot is dorsiflexed
- B. Pain when the chin is pulled down to the chest
- C. The inability of the child to extend the legs fully when lying supine
- D. The flexion of the hips when the neck is flexed from a lying position
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.