Nokea
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns and dietary intake
- B. Level and amount of physical activity
- C. Color and consistency of feces
- D. Presence and activity of bowel sounds
Correct Answer: A
Rationale: Eating patterns can affect the pain and inflammation in chronic pancreatitis, making this data crucial.
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A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation?
- A. Low-sodium soups.
- B. Over all fluid intake
- C. Tea and hot chocolate
- D. Citrus fruit juices
Correct Answer: C
Rationale: Tea and hot chocolate contain oxalates, which can contribute to the formation of calcium oxalate stones. Limiting these fluids helps prevent recurrence.
Blueberry muffin' lesions seen in rubella is due to
- A. Dermal erythropoiesis
- B. Thrombocytopenia
- C. Ecchymosis
- D. Vasculitis
Correct Answer: A
Rationale: Blueberry muffin' lesions in congenital rubella are due to dermal erythropoiesis, where extramedullary hematopoiesis occurs in the skin.
Which is an important nursing consideration when chest tubes will be removed from a child?
- A. Explain that it is not painful.
- B. Explain that only a Band-Aid will be needed.
- C. Administer analgesics before the procedure.
- D. Expect bright red drainage for several hours after removal.
Correct Answer: C
Rationale: It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.
Elevated levels of CPK are seen in:
- A. Duchenne muscular dystrophy
- B. Dermatomyositis
- C. Spinal muscular atrophy
- D. Malignant hyperthermia
Correct Answer: A
Rationale: Duchenne muscular dystrophy: Elevated creatine phosphokinase (CPK) levels are a hallmark of Duchenne muscular dystrophy due to muscle damage and degeneration.
The nurse is caring for a child with acute glomerulonephritis. Which of the following would most likely indicate that the child’s condition is improving?
- A. Increased urine output with normal color and consistency
- B. Decrease in the blood pressure
- C. A reduction in protein levels in the urine
- D. A decrease in hematuria
Correct Answer: A
Rationale: Improved renal function is indicated by increased urine output and the return of urine to normal color and consistency.