Nokea
A nurse is teaching a client with Addison's disease about its cause. What should the nurse say?
- A. It is caused by the overproduction of growth hormone.
- B. It is caused by the lack of production of aldosterone by the adrenal gland.
- C. It is caused by excess thyroid hormone.
- D. It is caused by overactive adrenal glands.
Correct Answer: B
Rationale: The correct answer is B: Addison's disease is caused by the lack of production of aldosterone by the adrenal gland. Aldosterone is a hormone produced by the adrenal glands that helps regulate blood pressure and electrolyte balance in the body. In Addison's disease, the adrenal glands do not produce enough aldosterone, leading to symptoms like low blood pressure, weakness, and electrolyte imbalances. Choice A is incorrect because Addison's disease is not caused by the overproduction of growth hormone. Choice C is incorrect as it mentions excess thyroid hormone, which is not related to Addison's disease. Choice D is incorrect because Addison's disease is characterized by underactive, not overactive, adrenal glands.
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A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
- A. Offer fluids to your child multiple times every day
- B. Offer fluids only during fever episodes.
- C. Give fluids only if the child asks for them.
- D. Limit fluid intake during a crisis to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A: Offer fluids to your child multiple times every day. This is important in sickle cell anemia to prevent dehydration and promote good blood flow, reducing the risk of sickling and subsequent crisis episodes. Adequate hydration helps maintain the flexibility of red blood cells and prevents them from clumping together. Options B, C, and D are incorrect because limiting fluid intake can lead to dehydration and worsen the symptoms of sickle cell anemia during and after a crisis episode. It is essential to encourage regular fluid intake to keep the child well-hydrated and prevent complications.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Use of public transportation
- C. Group activities
- D. Unrestricted visitors
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and plants can harbor bacteria and fungi that can potentially cause infections. Therefore, restricting fresh flowers and plants helps minimize the risk of infection. Choices B, C, and D are incorrect because they do not directly relate to the risk of infection in neutropenic clients. Using public transportation, engaging in group activities, or having visitors are generally safe as long as proper infection control measures are followed.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma often spreads to lymph nodes.
- C. Basal cell carcinoma is most common in young adults.
- D. Basal cell carcinoma is curable with chemotherapy.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. This should be included in the educational program because basal cell carcinoma rarely metastasizes. Metastasis is the spread of cancer from the original site to other parts of the body, and in the case of basal cell carcinoma, it tends to remain localized. This information is crucial for patients to understand the prognosis and treatment options.
Explanation of why other choices are incorrect:
B: Basal cell carcinoma often spreads to lymph nodes - This statement is incorrect as basal cell carcinoma typically does not spread to lymph nodes.
C: Basal cell carcinoma is most common in young adults - Basal cell carcinoma is more common in older individuals, typically over the age of 50.
D: Basal cell carcinoma is curable with chemotherapy - While chemotherapy may be a treatment option for some cases of basal cell carcinoma, it is not the primary treatment and not always curative.
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
- A. Continue to monitor the client.
- B. Notify the healthcare provider immediately.
- C. Increase the suction level.
- D. Reposition the client.
Correct Answer: A
Rationale: The correct answer is A. The rise in the water seal chamber with client inspiration indicates that the chest tube system is functioning properly. This rise is expected as the negative pressure in the pleural space increases during inspiration, causing the water level to momentarily increase. It is important for the nurse to understand this physiological response and continue to monitor the client for any signs of respiratory distress. Notifying the healthcare provider immediately or increasing suction level is unnecessary and may disrupt the client's respiratory status. Repositioning the client is not indicated in this situation.