Nokea
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
- A. Nephritis
- B. Cardiomegaly
- C. Desquamation
- D. Meningitis
Correct Answer: A
Rationale: Nephritis is the major complication of SLE due to immune complex deposition in the kidneys, leading to lupus nephritis, which can cause renal failure if untreated.
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The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
- A. Body image disturbance
- B. Risk for infection
- C. Sensory perceptual alterations
- D. Activity intolerance
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
- A. Cornflakes, whole milk, banana, and coffee
- B. Scrambled eggs, bacon, toast, and coffee
- C. Oatmeal, apple juice, dry toast, and coffee
- D. Pancakes, ham, tomato juice, and coffee
Correct Answer: C
Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.
According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):
- A. safety and security
- B. esteem
- C. physiological
- D. love and belonging
- E. self-actualization
Correct Answer: C,A,D,B,E
Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.