Nokea
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct Answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.
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After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to suck on ice chips
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.
A client is being treated for congestive heart failure with furosemide (Lasix). Which of these findings would be most concerning to the nurse?
- A. Increased urine output
- B. Decreased appetite
- C. Weight loss of 2 kg in 24 hours
- D. Blood pressure of 140/90 mm Hg
Correct Answer: C
Rationale: The correct answer is C. A rapid weight loss of 2 kg in 24 hours suggests significant fluid loss, which is concerning in clients on diuretics like furosemide. Increased urine output (choice A) is an expected effect of diuretic therapy. Decreased appetite (choice B) is a common side effect but not as concerning as rapid weight loss. Blood pressure of 140/90 mm Hg (choice D) is slightly elevated but not the most concerning finding in a client being treated for congestive heart failure with furosemide.
When speaking with a group of teens, which side effect of chemotherapy for cancer would the nurse expect this group to be more interested in discussing?
- A. Mouth sores
- B. Fatigue
- C. Diarrhea
- D. Hair loss
Correct Answer: D
Rationale: Hair loss is the correct answer. Teens are often more concerned about hair loss because of its visible impact and social implications. While mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, hair loss tends to be a significant concern for teens due to its effect on self-image and confidence.
A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am one of every 4 women that get fibroids, and among women my age - between the 30s or 40s, fibroids occur more frequently.
- B. My fibroids are noncancerous tumors that grow slowly.
- C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination, urine retention, and constipation.
- D. Fibroids that cause no problems still need to be taken out.
Correct Answer: D
Rationale: The correct answer is D because fibroids that are asymptomatic usually do not require treatment or removal. The statement 'Fibroids that cause no problems still need to be taken out' indicates a need for further education. Choice A correctly states the frequency of fibroids in women and their age group. Choice B accurately describes fibroids as noncancerous slow-growing tumors. Choice C lists common symptoms associated with uterine fibroids.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: B
Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.