Nokea
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.
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A narcotic analgesic is ordered for postoperative pain. Why are narcotics given in low doses to the laryngectomy patient?
- A. They depress the respiratory rate and cough reflex.
- B. They increase respiratory tract secretions.
- C. They have a tendency to cause stomal edema.
- D. They can cause addiction.
Correct Answer: A
Rationale: The correct answer is A because narcotics in high doses can depress the respiratory rate and cough reflex, which can be especially dangerous for a laryngectomy patient due to the risk of airway compromise. Low doses can provide pain relief without significant respiratory depression. Choices B and C are incorrect because narcotics typically do not increase respiratory tract secretions or cause stomal edema. Choice D is incorrect because while narcotics can potentially cause addiction, this is not the primary reason for giving low doses to laryngectomy patients.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.
For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: C
Rationale: The correct answer is C because it focuses on the client actively engaging in reducing tension, which is essential in managing anxiety. This outcome is measurable and client-centered.
A: Verbalizing feelings is important, but it does not necessarily lead to reduction in anxiety.
B: Not guessing prognosis is helpful, but it does not address the active management of anxiety.
D: Stopping seeking information may not be beneficial as knowledge can empower the client in coping with the diagnosis.
When monitoring for hypernatremia, the nurse should assess the client for:
- A. Dry skin
- B. Tachycardia
- C. Confusion
- D. Pale coloring
Correct Answer: C
Rationale: The correct answer is C: Confusion. Hypernatremia is an electrolyte imbalance characterized by high sodium levels in the blood. Confusion is a common symptom as high sodium levels can affect brain function. Dry skin (A) is more indicative of dehydration, tachycardia (B) is a symptom of various conditions, and pale coloring (D) is not specific to hypernatremia. Confusion is a key indicator that the nurse should assess for when monitoring for hypernatremia.