Nokea
The nurse practitioner assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs and tissues in the body. The assessment findings listed in option B are more indicative of SLE:
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How many liters per minute of oxygen should be administered to the patient with emphysema?
- A. 2 L/min
- B. 10 L/min
- C. 6 L/min
- D. 95 L/min
Correct Answer: C
Rationale: Oxygen therapy for patients with emphysema aims to maintain adequate oxygen levels in the blood while avoiding toxic levels of oxygen. The recommended flow rate for oxygen administration in patients with emphysema is typically 1-3 liters per minute. Increasing the flow rate above this range may lead to oxygen toxicity in these patients. Therefore, a safe and appropriate oxygen flow rate for a patient with emphysema would be around 6 L/min, making option C, 6 L/min, the correct choice from the provided options.
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
- A. Encourage 3 to 4 L of fluid daily
- B. Place the patient on bed rest
- C. Have the patient cough and deep
- D. Apply heat to painful areas breathe every 2 hours
Correct Answer: A
Rationale: Encouraging a high fluid intake, typically around 3 to 4 liters daily, is an intervention that can help minimize complications related to hypercalcemia. Adequate hydration helps prevent the formation of kidney stones, a common complication of hypercalcemia. The increased fluid intake can also promote renal excretion of excess calcium, aiding in its elimination from the body. Additionally, adequate hydration supports overall kidney function and can help prevent renal damage that may result from high calcium levels.
Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
- A. Negative scarf sign
- B. Asymmetric Moro reflex
- C. Swelling of fingers on affected side
- D. Paralysis of affected extremity and muscles
Correct Answer: C
Rationale: A newborn with a clavicle fracture may present with swelling of the fingers on the affected side. This is due to the injury disrupting the nerves and blood vessels that supply the arm, leading to edema and swelling in the fingers. The other signs mentioned in the options are not typically associated with a clavicle fracture. A negative scarf sign relates to positioning of the arm and is not specific to a clavicle fracture. Asymmetric Moro reflex can be a normal finding in newborns and not indicative of a fracture. Paralysis of the affected extremity and muscles would be more suggestive of a nerve injury rather than a clavicle fracture.
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: Acute respiratory distress syndrome (ARDS) is a serious condition that can lead to various complications, including renal failure. When a client is experiencing ARDS, the lungs become severely inflamed and filled with fluid, which can lead to decreased oxygen levels in the blood. This decrease in oxygen can place a significant strain on the kidneys, potentially resulting in renal failure. Therefore, it is crucial for nurses to monitor the client for signs and symptoms of renal failure, such as changes in urine output, fluid imbalance, electrolyte abnormalities, and altered mental status. Timely detection and management of renal complications in clients with ARDS are essential to prevent further deterioration of the client's condition.
Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)?
- A. Superficial lesions over the cheek and
- B. Weight loss nose
- C. Difficulty urinating
Correct Answer: A
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs in the body. One of the classic signs of SLE is the presence of a facial rash in the shape of a butterfly over the cheeks and bridge of the nose. This rash is known as a malar rash and is often one of the first visible symptoms of the disease. Weight loss and difficulty urinating are not typical signs of SLE.