Nokea
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.
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Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.
The nurse is reading the results of a tuberculin skin test (see fi gure). The nurse should interpret the results as:
- A. Negative
- B. Needing to be repeated.
- C. Positive.
- D. False.
Correct Answer: C
Rationale: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purifi ed protein derivative (PPD) by measuring the size of the fi rm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a fi rm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate?
- A. Surgery is usually required, although medical treatment is attempted first.'
- B. Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes.'
- C. Surgery is not performed for this type of hernia.'
- D. A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.'
Correct Answer: B
Rationale: Most hiatal hernias are managed effectively with diet, medications, and lifestyle changes, making this the most accurate response.
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?
- A. Administer the medications.
- B. Call the physician.
- C. Withhold the captopril.
- D. Question the metoprolol dose.
Correct Answer: B
Rationale: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.