Nokea
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
- A. Passage of liquid stool from the stoma.
- B. Occasional presence of undigested food in the effluent.
- C. Absence of drainage from the ileostomy for 6 or more hours.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize
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The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
- A. Widening pulse pressure.
- B. Decrease in the pulse rate.
- C. Dilated, fixed pupils.
- D. Decrease in level of consciousness (LOC).
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
- A. Providing activities of daily living on the time schedule that the client wishes.
- B. Offering foods that the client enjoys in order to increase the intake of calories.
- C. Decreasing cardiac demands by promoting rest.
- D. Listening to concerns about the hospitalization.
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.
A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
- A. Decrease fat in the diet, decrease alcohol consumption, and use sunscreen every day.
- B. Decrease intake of salt-cured food, lose weight, and stop smoking.
- C. Stop drinking beer, decrease fiber in the diet, and use sun protection.
- D. Stop smoking, use sun protection, and lose weight.
Correct Answer: D
Rationale: Stopping smoking, using sun protection, and losing weight address the most critical modifiable risk factors for this client, given her smoking history, prior skin cancer, and obesity, which are linked to multiple cancers.
A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:
- A. Vertigo.
- B. Facial paralysis.
- C. Impaired vision.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Streptomycin can damage the eighth cranial nerve (vestibulocochlear), causing vertigo or hearing loss. Facial paralysis, impaired vision, and difficulty swallowing are associated with other cranial nerves.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.