Nokea
The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?
- A. A sweat potassium concentration less than 40 mEq/L
- B. A sweat chloride concentration greater than 60 mEq/L
- C. A sweat potassium concentration greater than 40 mEq/L
- D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B
Rationale: A sweat chloride concentration >60 mEq/L is diagnostic for cystic fibrosis due to defective chloride channels. Potassium levels are not diagnostic, and low chloride is normal.
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A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.'
- B. If I have any side effects from my medicines, I will take an extra dose of Cogentin.'
- C. When I get home, I should be able to taper myself off the Haldol because the voices are gone now.'
- D. As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway.'
Correct Answer: A
Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Correct Answer: C
Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.
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.