Nokea
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.
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A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge helps stretch the knee joints and prevent flexion contractures in rheumatoid arthritis. The other positions do not address knee extension.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum endometritis is treated with antibiotics to address the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
- A. Fever, runny nose, and hyperactivity
- B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes
- C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness
- D. Fever, cough, paleness, and wheezing
Correct Answer: C
Rationale: The child with asthma may not have fever unless there is an underlying infection. Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. Coughing and wheezing are not early signs of difficulty.
The family member of a child scheduled for heart surgery states, 'I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?' The nurse explains that patent ductus arteriosus repair is:
- A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Correct Answer: B
Rationale: Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. Patent ductus arteriosus is a ductus arteriosus that does not close shortly after birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. Percutaneous transluminal coronary angioplasty is a closed-heart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:
- A. Avoid salty foods
- B. Increase fluid intake
- C. Take the medication with meals
- D. Monitor for weight loss
Correct Answer: B
Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.