Nokea
The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply.
- A. Chest physiotherapy is administered only if respiratory symptoms worsen.
- B. I will give my child pancreatic enzymes with all meals and snacks.
- C. I will increase my child's salt intake during hot weather.
- D. Our child will need a high-carbohydrate, high-protein diet.
- E. We will limit our child's participation in sports activities.
Correct Answer: B,C,D
Rationale: Pancreatic enzymes with meals (B), increased salt in hot weather (C), and a high-calorie, high-protein diet (D) are correct for cystic fibrosis management. Chest physiotherapy (A) is routine, not symptom-based, and limiting sports (E) is unnecessary unless advised.
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A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.
The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.