Nokea
The nurse is collecting data from a client with primary adrenal insufficiency (Addison disease). Which of the following findings is consistent with the condition?
- A. Bronze pigmentation of the skin
- B. Increased body and facial hair
- C. Purple or red striae on the abdomen
- D. Supraclavicular fat pad
Correct Answer: A
Rationale: Bronze skin pigmentation (A) is a hallmark of Addison disease due to increased ACTH stimulating melanocytes. Increased hair (B) and supraclavicular fat pad (D) are associated with Cushing syndrome, while striae (C) are nonspecific but not typical of Addison disease.
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While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that:
- A. psychiatric illness is more prevalent in addicted populations.
- B. people with psychiatric disorders are more prone to substance abuse.
- C. substance disorders are easily detected and diagnosed in acute-care psychiatric settings.
- D. undetected substance problems have no real effect on treatment of psychiatric disorders.
Correct Answer: B
Rationale: The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur.
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that:
- A. Toddlers often misbehave to get the attention of adults.
- B. Toddlers are able to use thought processes to experience events and reactions.
- C. Negative actions that are not immediately punished will be repeated.
- D. Manipulation of objects in their environment enables the toddler to learn about spatial relationships.
Correct Answer: D
Rationale: Toddlers explore spatial relationships through actions like shaking a cup, not necessarily to misbehave. Attention-seeking or punishment is less relevant.