Nokea
The nurse should monitor the client with Cushing's disease for which of the following?
- A. Postprandial hypoglycemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Decreased urine calcium level.
Correct Answer: B
Rationale: Hypokalemia is common in Cushing's disease due to aldosterone excess, causing potassium loss.
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The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms
- B. Loss of sensation in his hands and fingers.
- C. Dysfunction of bowel and bladder.
- D. Difficulty breathing.
Correct Answer: C
Rationale: This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
- A. Decreased pain
- B. Increased urinary output
- C. Decreased blood pressure
- D. Decreased temperature
- E. Increased muscle coordination
Correct Answer: A,D
Rationale: Ketorolac, an NSAID, reduces pain and inflammation, which can lower temperature in febrile clients. It does not directly affect urinary output, blood pressure, or muscle coordination.
Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client:
- A. Has severe chest pain.
- B. Can identify risk factors for MI.
- C. Agrees to participate in a cardiac rehabilitation walking program.
- D. Can perform personal self-care activities without pain.
Correct Answer: D
Rationale: By the second day post-MI, the client should be able to perform self-care activities without pain, indicating stabilization. Severe pain is not expected, and risk factor identification or rehabilitation planning may occur later.
Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:
- A. Assess the urine output
- B. Place a large bore I.V.
- C. Position onto the left side
- D. Insert a nasogastric tube
Correct Answer: B
Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.
A client is admitted to the emergency department with a full thickness burn to his right arm. Upon assessment, the arm is edema, the agent is mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10 . The nurse should:
- A. Administer morphine sulfate I.V. push for the severe pain.
- B. Call the physician to report the loss of the radial pulse.
- C. Continue to assess the arm every hour for any additional changes.
- D. Instruct the client to exercise his fingers and wrist.
Correct Answer: B
Rationale: The absence of the radial pulse indicates potential compartment syndrome or vascular compromise, which is a medical emergency requiring immediate physician notification to prevent tissue necrosis.