Nokea
The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:
- A. Chronic liver failure.
- B. Pathologic bone fractures.
- C. Acute heart failure.
- D. Hypoxemia.
Correct Answer: B
Rationale: Clients with multiple myeloma are at increased risk for pathologic bone fractures due to the disease's effects on bone tissue. Multiple myeloma is a cancer of plasma cells, a type of white blood cell found in the bone marrow. The growth of abnormal plasma cells weakens the bone structure, leading to bone lesions and an increased risk of fractures. The bone lesions can cause pain, bone deformities, and complications such as hypercalcemia. Therefore, nurses caring for clients with multiple myeloma should prioritize interventions to prevent pathologic bone fractures and manage bone health.
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An adolescent girl asks the school nurse for advice because she has dysmenorrhea. She says that a friend recommended she try an over-the-counter nonsteroidal anti-inflammatory drug (NSAID). The nurse's response should be based on which statement?
- A. Aspirin is the drug of choice for the treatment of dysmenorrhea.
- B. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief.
- C. NSAIDs are effective because of their analgesic effect.
- D. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in uterine activity.
Correct Answer: D
Rationale: NSAIDs are effective for treating dysmenorrhea because they work by inhibiting prostaglandins, which are responsible for causing increased uterine activity and thus pain during menstruation. By reducing prostaglandin levels, NSAIDs help to decrease uterine contractions and consequently alleviate menstrual cramps. This mechanism of action makes NSAIDs an appropriate and effective choice for managing dysmenorrhea.
Which is an important nursing action related to the use of tape and/or adhesives on preterm newborns?
- A. Avoid using tape and adhesives until skin is more mature.
- B. Use solvents to remove tape and adhesives instead of pulling on skin.
- C. Remove adhesives with warm water or mineral oil.
- D. Use scissors carefully to remove tape instead of pulling tape off.
Correct Answer: A
Rationale: An important nursing action related to the use of tape and/or adhesives on preterm newborns is to avoid using tape and adhesives until the skin is more mature. Preterm newborns have delicate and fragile skin that is more prone to damage and injury. Using tape and adhesives on immature skin can increase the risk of skin tears, irritations, and damage. It is recommended to wait until the skin matures and becomes less delicate before using tape or adhesives on preterm newborns to prevent skin-related complications.
The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client's voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The nurse should observe for muscle twitching and numbness or tingling of the lips, fingers, and toes in a client who had a thyroidectomy and is at risk for hypocalcemia. Hypocalcemia is a potential complication following thyroidectomy because the parathyroid glands may be inadvertently removed or damaged during the surgery, leading to decreased calcium levels in the blood. Symptoms of hypocalcemia include muscle twitching (especially in the face), and numbness or tingling around the lips, fingers, and toes. Prompt recognition of these symptoms is crucial as severe hypocalcemia can lead to more serious complications, such as seizures and laryngospasm. Monitoring for these signs allows the nurse to intervene early and prevent further complications.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The symptoms described in the scenario, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, are indicative of an immediate hypersensitivity reaction, also known as a Type I hypersensitivity reaction. This type of reaction is triggered by the release of histamine and other inflammatory mediators from mast cells and basophils. Symptoms can range from mild to severe and can manifest rapidly after exposure to the allergen, in this case, the blood transfusion. Common manifestations include skin reactions (e.g., itching, urticaria), respiratory symptoms (e.g., chest pain, wheezing), cardiovascular changes (e.g., tachycardia, hypotension), and gastrointestinal symptoms (e.g., nausea, vomiting).
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.