Nokea
The nurse should assess a client with Addison's disease for which of the following?
- A. Weight gain.
- B. Orthostatic hypotension.
- C. Lethargy.
- D. Muscle spasms.
Correct Answer: B
Rationale: Orthostatic hypotension is common in Addison's disease due to aldosterone deficiency, causing sodium and fluid loss.
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A client with cancer is admitted with suspected disseminated intravascular coagulation (DIC). Which laboratory finding supports this diagnosis?
- A. Prolonged prothrombin time (PT).
- B. Elevated hemoglobin.
- C. Normal platelet count.
- D. Decreased D-dimer.
Correct Answer: A
Rationale: DIC causes abnormal clotting and bleeding, leading to a prolonged prothrombin time (PT) due to consumption of clotting factors, supporting the diagnosis.
A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
- A. Slow, irregular respirations.
- B. Rapid, shallow respirations.
- C. Asymmetric chest excursion.
- D. Nasal flaring.
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.
Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication?
- A. Gastrointestinal bleeding.
- B. Myocardial infarction.
- C. Emesis.
- D. Rib fracture.
Correct Answer: D
Rationale: Incorrect hand placement during CPR can cause rib fractures, which, while sometimes unavoidable, can be minimized with proper technique, such as placing hands at the center of the chest over the lower half of the sternum.
The nurse is teaching an older adult client with a history of heat exhaustion. Which of the following statements by the client indicates a need for further teaching?
- A. I should take a cool shower after being outdoors in very hot weather.
- B. I can place ice packs on my neck, chest, and stomach after being outdoors in the heat.
- C. I should wear lightweight, light-colored, and loose-fitting clothing when working outside on very hot days.
- D. I should consume water and take my salt tablets when I am outside gardening on very hot days.
Correct Answer: B
Rationale: Using ice packs can cause vasoconstriction or tissue damage and is not recommended for heat exhaustion. Cool showers (A), appropriate clothing (C), and hydration (D) are correct, but salt tablets are unnecessary with adequate diet and hydration.