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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 client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
- A. Osmolarity
- B. Glucose
- C. Albumin
- D. Platelets
Correct Answer: B
Rationale: Hydrocortisone can affect blood glucose levels, making it important to monitor for hyperglycemia.
When planning care for a 8-year-old boy with Down syndrome, the nurse should:
- A. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
- B. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
- C. Assess the child’s current developmental level and plan care accordingly
- D. Direct all teaching to the parents because the child can’t understand
Correct Answer: C
Rationale: Care should be individualized based on the child’s current developmental level, not just their chronological age or assumptions about delays.
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
- A. True urinary output of 50ml/hr
- B. Lower abdominal tenderness
- C. Blood urine output with clots
- D. Urine leaking around the meatus
Correct Answer: D
Rationale: Urine leaking around the meatus may indicate catheter displacement or obstruction, requiring immediate attention to prevent complications.
An 8-year-old from the former Soviet Union is brought to your office because of a heart murmur and dusty blue skin. He has marked clubbing of his fingers and toes, and his hematocrit is 70%. He has a grade 4/6 holosystolic murmur. His chest x-ray reveals a normal pulmonary blood flow as well as a right-sided aortic arch. What is the likely diagnosis?
- A. total anomalous venous return
- B. tetralogy of Fallot
- C. Eisenmenger syndrome
- D. transposition of the great vessels
Correct Answer: C
Rationale: Eisenmenger syndrome involves reversal of shunt direction due to long-standing pulmonary hypertension, explaining the cyanosis and clubbing.
Patients who have undergone surgery entailing the use of cardiopulmonary bypass should be watched carefully for
- A. epilepsy disabilities
- B. learning disabilities
- C. anemia
- D. arrhythmias
Correct Answer: D
Rationale: Arrhythmias are a common complication after cardiopulmonary bypass surgery.