Nokea
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
- A. Alcohol promoted the formation of calculi in the cystic duct.
- B. The pancreas is stimulated to secrete more insulin than it can immediately produce.
- C. The alcohol alters the composition of enzymes so they are capable of damaging the pancreas.
- D. Alcohol increases enzyme secretion and pancreatic duct pressure and causes backflow of enzymes into the pancreas.
Correct Answer: D
Rationale: Alcohol causes enzyme backflow, leading to pancreatic autodigestion.
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Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
For which of the following conditions might blood be drawn for uric acid level?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels, which are measured to confirm diagnosis and monitor treatment. The other conditions do not typically involve uric acid testing. Reduction of Risk Potential
A nurse is assessing a newborn who is 1 hour old. Which of the following findings should be reported to the healthcare provider? (Select all that apply)
- A. Respiratory rate of 50 breaths per minute
- B. Nasal flaring
- C. Grunting
- D. Temperature of 36.5°C (97.7°F)
Correct Answer: B,C
Rationale: Nasal flaring and grunting indicate respiratory distress, requiring immediate reporting. A respiratory rate of 50 and temperature of 36.5°C are normal for a newborn.
The client is receiving chemotherapy for cancer. Which statement, if made by the client, would indicate that she has accepted the diagnosis and treatment?
- A. I hate getting that treatment.'
- B. The doctor isn't sure if I really have cancer.'
- C. I have a collection of pretty scarves that I am wearing a lot now.'
- D. I don't go anywhere except for my treatments because I look so weird.'
Correct Answer: C
Rationale: Wearing scarves suggests acceptance of chemotherapy-induced hair loss, indicating adaptation to treatment and diagnosis.
The nurse is assigned to a patient newly diagnosed with active tuberculosis.
Which of these interventions would be a priority for the nurse to implement?
- A. Have the client cough into a tissue and dispose in a separate bag
- B. Instruct the client to cover the mouth with a tissue when coughing
- C. Reinforce that everyone should wash their hands before and after entering the room
- D. Place client in a negative pressure private room and have all who enter the room use masks with shields
Correct Answer: D
Rationale: A negative pressure room and masks prevent airborne transmission of tuberculosis, a priority for infection control.