Nokea
The nurse is caring for a person who is admitted with progressive amyotrophic lateral sclerosis (ALS). What nursing care measure should the nurse expect to be ordered for this client?
- A. Change dressing daily
- B. Monitor IV fluids
- C. Insert indwelling catheter
- D. Chest physical therapy (PT) qid
Correct Answer: D
Rationale: ALS causes respiratory muscle weakness; chest PT helps clear secretions, preventing pneumonia. Dressings, fluids, or catheters are not primary.
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The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
- A. erythema
- B. leukocytosis
- C. pressurelike pain
- D. swelling
Correct Answer: C
Rationale: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation
Which of the following is considered a sequela of a staphylococcal infection that may result to glomerulonephritis?
Infected burn wound
- A. Impetigo
- B. Skin problem from chickenpox
- C. Herpes simplex
Correct Answer: B
Rationale: Impetigo is a bacterial infection of the skin caused by streptococci or staphylococci. Group A hemolytic streptococci can cause rheumatic fever and glomerulonephritis.
Hirschprung's Disease is somewhat similar to cystic fibrosis. In both diseases, the newborn does not pass out meconium.
Pathophysiologically, in Hirschprung's Disease, the child's affected organ is:
- A. Small intestine
- B. Large intestine
- C. Stomach
- D. Liver
Correct Answer: B
Rationale: Hirschprung's disease involves aganglionic segments of the large intestine, causing obstruction.