Nokea
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
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A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) best reflects the client's symptoms of tiring rapidly due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported.
A 60-year-old female with chronic cancer pain has been receiving opiates for 4 months. She rated her pain as an 8 on a 10-point scale before starting the opioid medication. She has just had a thorough examination with no new evidence of increased disease, yet her pain is close to 8 again. The most likely explanation for her increasing pain is:
- A. Development of an addiction to the opioids.
- B. Tolerance to the opioid.
- C. Withdrawal from the opioid.
- D. Placebo effect has decreased.
Correct Answer: B
Rationale: Tolerance to opioids is the most likely explanation, as the body adapts to the medication over time, reducing its effectiveness and requiring a dose adjustment.
A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:
- A. Hiatal hernia.
- B. Stomatitis.
- C. Radiation enteritis.
- D. Esophagitis.
Correct Answer: D
Rationale: Pain while swallowing and chest burning/tightness suggest esophagitis, a common side effect of chest wall radiation due to irritation of the esophageal mucosa.