Nokea
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
- A. The delay of the impending death
- B. Offering a caring support system
- C. Providing measure focused on pain management
- D. Introduction of interventions that enhance the quality of life
- E. Expanding the focus of care to both the client and the family
- F. Addressing the expressed spiritual needs of the client and the family
Correct Answer: B,C,D,E,F
Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: offering a support system to help the client live as actively as possible until death; providing relief from pain and other distressing symptoms; enhancing the quality of life; offering a support system to help families cope during the client's illness and their own bereavement; affirming life and regarding dying as a normal process, neither hastening nor postponing death; and integrating psychological and spiritual aspects of client care.
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A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.
- A. Cardiac murmur
- B. Cardiac enlargement
- C. Cool pale skin over the joints
- D. White painful skin lesions on the trunk
- E. Small nontender lumps on bony prominences
- F. Purposeless jerky movements of the extremities and face
Correct Answer: A,B,E,F
Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A. Bowel sounds
- B. Chewing ability
- C. Current appetite
- D. Food preferences
Correct Answer: B
Rationale: The nurse needs to assess the client's chewing ability before advancing a client from liquid to solid food. It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing because of the risk of aspiration. Bowel sounds should be present before introducing any diet, including liquids. Appetite will affect the amount of food eaten, but not the type of diet prescribed. Food preferences should be ascertained on admission assessment.
The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? Select all that apply.
- A. Lift the cast using the fingertips.
- B. Place the child on a firm mattress.
- C. Direct a fan toward the cast to facilitate drying.
- D. Support the cast and adjacent joints with pillows.
- E. Place the extremity with the cast in a dependent position.
- F. Reposition the extremity with the cast every 2 to 4 hours.
Correct Answer: B,C,D,F
Rationale: To help the cast dry, the child should be placed on a firm mattress. A fan may be directed toward the cast to facilitate drying. Once the cast is dry, the cast should sound hollow and be cool to touch. The cast and adjacent joints should be elevated and supported with pillows. To ensure thorough drying, the extremity with the cast should be repositioned every 2 to 4 hours. The cast is lifted by using the palms of the hands (not the fingertips) to prevent indentation in the wet cast surface. Indentations could possibly cause pressure on the skin under the cast.
A client admitted to the hospital is suspected of having Guillain-Barré syndrome. Which assessment findings should the nurse identify as manifestations of this disorder? Select all that apply.
- A. Dysphagia
- B. Paresthesia
- C. Facial weakness
- D. Difficulty speaking
- E. Hyperactive deep tendon reflexes
- F. Descending symmetrical muscle weakness
Correct Answer: A,B,C,D
Rationale: Guillain-Barré syndrome is an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. Motor manifestations include ascending symmetrical muscle weakness that leads to flaccid paralysis without muscle atrophy, decreased or absent deep tendon reflexes, respiratory compromise and respiratory failure, and loss of bladder and bowel control. Sensory manifestations include pain (cramping) and paresthesia. Cranial nerve manifestations include facial weakness, dysphagia, diplopia, and difficulty speaking. Autonomic manifestations include labile blood pressure, dysrhythmias, and tachycardia.