Nokea
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings would be MOST concerning?
- A. Blood pressure of 80/50 mmHg with a pulse of 50.
- B. Temperature of 99°F (37.2°C).
- C. Spasticity in the lower extremities.
- D. Numbness in the hands and fingers.
Correct Answer: A
Rationale: A T4 spinal cord injury can cause autonomic dysreflexia or neurogenic shock, leading to severe hypotension (80/50) and bradycardia (pulse 50), which are life-threatening and require immediate intervention. Low-grade fever (B), spasticity (C), and numbness (D) are expected or less urgent.
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The nurse administers prescribed pancreatin replacement therapy to Bonnie.
To effectively evaluate the effect of this treatment, should expect that this medication will result to
- A. Bulky, foul, smelly stools.
- B. Close to normal stools.
- C. Loose, frequent stools.
- D. Constipation.
Correct Answer: B
Rationale: Pancreatin aids fat digestion, resulting in near-normal stools in pancreatic insufficiency.
Which of the following lab reports indicates that a client with acute glomerulonephritis is improving?
- A. Positive ASO titer
- B. Increased C reactive protein
- C. Negative eosinophil count
- D. Decreased erythrocyte sedimentation rate
Correct Answer: D
Rationale: A decreased erythrocyte sedimentation rate indicates reduced inflammation, suggesting improvement in acute glomerulonephritis.
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
- A. A private room down the hall from the nurses' station
- B. An isolation room close to the nurses' station
- C. A semiprivate room with a 32-year-old client who has viral meningitis
- D. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: B
Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.