Nokea
The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms.
- B. Loss of sensation in his hands and fingers.
- C. Incontinence of bowel and bladder.
- D. Spasticity of the lower extremities.
Correct Answer: C
Rationale: Incontinence is expected with spinal cord injuries due to disruption of neural control over bowel and bladder.
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The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which of the following details should the nurse include?
- A. Hemochromatosis is an autoimmune disorder that affects the HFE gene.
- B. Individuals who are heterozygous for hemochromatosis rarely develop the disease.
- C. Individuals who are homozygous for hemochromatosis are carriers of hemochromatosis.
- D. Men are at greater risk for hemochromatosis.
Correct Answer: B,D
Rationale: Hemochromatosis is a genetic disorder caused by HFE gene mutations, not an autoimmune condition. Heterozygous individuals rarely develop the disease, as two mutated genes are typically required. Homozygous individuals have the disease, not just carriers. Men are at greater risk due to higher iron accumulation (women lose iron via menstruation). These points should be included in teaching.
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply.
- A. I will need to dispose of my old clothing when I return home.
- B. I should always cover my mouth and nose when sneezing.
- C. I'll be important that I isolate myself from family when possible.
- D. I should use paper tissues to cough in and dispose of them promptly.
- E. I can use regular plates and utensils whenever I eat.
Correct Answer: B,D,E
Rationale: Covering the mouth when sneezing (B), using tissues for coughing and disposing of them (D), and using regular utensils (E) prevent tuberculosis spread. Disposing of clothing is unnecessary. Isolation is only needed until the client is non-infectious (after 2–3 weeks of treatment).
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
The nurse is caring for a client diagnosed with Reye's syndrome. The nurse understands that this illness is caused by which medication?
- A. Ibuprofen
- B. Aspirin
- C. Acetaminophen
- D. Diphenhydramine
Correct Answer: B
Rationale: Reye's syndrome is associated with aspirin use, particularly in children with viral infections, leading to liver and brain complications.
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for injury with compression over the xiphoid process?
- A. Lung.
- B. Liver.
- C. Stomach.
- D. Diaphragm.
Correct Answer: B
Rationale: Compressing the xiphoid process risks liver injury, as it lies directly beneath, potentially causing laceration or hemorrhage.