Nokea
The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?
- A. Hyperpigmentation of the skin.
- B. Low blood pressure.
- C. Nausea and vomiting.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.
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A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?
- A. hepatitis B
- B. tetanus, diphtheria, and pertussis (Tdap)
- C. varicella
- D. measles, mumps, and rubella (MMR)
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?
- A. Blood glucose of 250 mg/dL.
- B. Serum potassium of 3.5 mEq/L.
- C. Serum sodium of 135 mEq/L.
- D. Arterial blood pH of 7.30.
Correct Answer: D
Rationale: Corrected Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.
A public health nurse is planning a vaccination clinic for a rural community. Which vaccine should the nurse prioritize for adults in this area?
- A. hepatitis A
- B. influenza
- C. varicella
- D. measles, mumps, rubella (MMR)
Correct Answer: B
Rationale: The correct answer is 'B: influenza.' Influenza vaccination is crucial for adults, particularly in rural areas where access to healthcare may be limited. Influenza can cause serious illness and complications, and vaccination helps protect individuals and prevent the spread of the virus. While vaccines for hepatitis A, varicella, and measles, mumps, rubella (MMR) are important, prioritizing influenza vaccination in this scenario is essential due to its seasonal prevalence and potential impact on public health.
The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.