Nokea
The nurse is teaching the parent of a child newly diagnosed with JRA. The nurse would evaluate the teaching as successful when the parent is able to say that the disorder is caused by:
- A. The breakdown of osteoclasts in the joint space causing bone loss.
- B. The loss of cartilage in the joints.
- C. The buildup of calcium crystals in joint spaces.
- D. The immune-stimulated inflammatory response in the joint.
Correct Answer: D
Rationale: The correct answer is D. Juvenile rheumatoid arthritis (JRA) is caused by the immune-stimulated inflammatory response in the joints. In JRA, the body's immune system attacks its own healthy joint tissues, leading to inflammation, pain, and damage to the joints. This chronic inflammation can cause joint stiffness, swelling, and in severe cases, joint deformities. It is not caused by the breakdown of osteoclasts in the joint space (A), the loss of cartilage in the joints (B), or the buildup of calcium crystals in joint spaces (C).
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.
After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
- A. 3150ml
- B. 3650 ml
- C. 3200 ml
- D. 3750ml
Correct Answer: C
Rationale: To calculate the total IV fluid intake for 24 hours, we will add up the volume of each type of fluid ordered.
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mEq/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The patient is displaying signs of hypokalemia (low potassium levels) due to severe vomiting. Symptoms of hypokalemia can include weakness, fatigue, and ECG changes such as flat T waves and ST segment depression. The potassium level that is most likely associated with these symptoms is 2.0mEq/L. Severe vomiting can lead to significant loss of potassium from the body, causing these abnormalities. It is important to address and correct the potassium imbalance to prevent further complications.
Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia?
- A. Increased hemoglobin
- B. Normal hematocrit
- C. Decreased mean corpuscular volume (MCV)
- D. Normal total iron-binding capacity (TIBC)
Correct Answer: C
Rationale: Iron deficiency anemia is characterized by a decreased mean corpuscular volume (MCV) due to the microcytic red blood cells that result from inadequate iron availability for hemoglobin synthesis. This leads to smaller red blood cells, which are reflected in a decreased MCV. Iron deficiency anemia would not typically result in an increased hemoglobin or normal hematocrit since the lack of iron impairs the production of red blood cells. Additionally, the total iron-binding capacity (TIBC) would usually be increased in iron deficiency anemia as the body attempts to compensate for the decreased iron levels by increasing its ability to bind and transport iron. Therefore, the nurse would expect a decreased mean corpuscular volume (MCV) in a child with iron deficiency anemia.
Approximately how much fluid is lost in acute weight loss of .5kg?
- A. 50 ml
- B. 750 ml
- C. 500 ml
- D. 75 ml
Correct Answer: C
Rationale: When a person loses 0.5 kg of weight, it is commonly assumed that most of the weight loss is due to fluid loss. The approximate fluid loss for every 0.5 kg of weight loss is around 500 ml. This estimation is based on the fact that 1 kg of body weight is approximately equivalent to 1 liter of fluid. Therefore, for a 0.5 kg weight loss, the fluid loss would be approximately 500 ml (0.5 liters).