Nokea
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The nursing care for a client in Addisonian crisis, also known as adrenal crisis, should include offering extra blankets and raising the heat in the room to keep the client warm. Addisonian crisis is a life-threatening condition that occurs when the body does not have enough cortisol and aldosterone, which are hormones produced by the adrenal glands. Symptoms of Addisonian crisis include severe weakness, fatigue, abdominal pain, nausea, vomiting, and low blood pressure. By offering extra blankets and raising the room temperature, the nurse can help prevent hypothermia, which can worsen the client's condition. It is important to maintain the client's body temperature to promote comfort and prevent further complications during Addisonian crisis.
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A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: Chemotherapy can cause fluid and electrolyte imbalances in the body, leading to potential kidney damage and altered urinary output. A low urine output of 400 ml in 8 hours could indicate dehydration or impaired renal function, both of which can be induced by chemotherapy. Monitoring urine output is crucial in assessing the patient's fluid balance and kidney function during chemotherapy. It is essential to identify and address such imbalances promptly to prevent complications.
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The observation that indicates adequate tissue perfusion to vital organs is a urinary output of 30 ml in an hour. Adequate tissue perfusion is essential to ensure that vital organs receive enough blood and oxygen. Monitoring urinary output is a crucial indicator of perfusion status, as it reflects the perfusion of the kidneys. A urinary output of at least 30 ml/hour or more indicates that the kidneys are receiving sufficient blood flow and are able to produce urine, which helps in removing waste products from the body. In this case, a urinary output of 30 ml in an hour suggests adequate tissue perfusion to vital organs. The other options do not directly reflect tissue perfusion to vital organs and may indicate inadequate perfusion or compromised hemodynamic status.
An adult is on long term aspirin therapy and is experiencing tinnitus. What is the best interpretation of this occurrence?
- A. The aspirin is working correctly
- B. The client has an upper GI bleed
- C. The client has a metal taste in their mouth
- D. The client is experiencing a mild overdosage
Correct Answer: D
Rationale: Tinnitus (ringing in the ears) is a potential side effect of aspirin overdose. Aspirin can cause toxicity with symptoms like ringing in the ears, dizziness, confusion, and nausea. It is important for the adult to seek medical attention if they are experiencing tinnitus while on long-term aspirin therapy to address the possible overdose situation.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- B. Carcinoma is situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- C. Can't assess tumor or regional lymph nodes and no evidence of metastasis
- D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer: B
Rationale: In the TNM staging system, "T" represents the extent of the primary tumor, "N" refers to the involvement of regional lymph nodes, and "M" indicates the presence of distant metastasis. In the given classification of TIS, N0, M0:
A nurse is assessing a 5 year old with a history of heart failure. Which finding indicates that the child has adequate cardiac output?
- A. Urine output of 30 mL/h
- B. Heart rate of 120 beats/min
- C. Cap refill time of 10 to 15 sec
- D. Bilateral crackles heard on auscultation.
Correct Answer: A
Rationale: Adequate cardiac output is a measure of how well the heart is able to pump blood effectively to meet the body's metabolic demands. An adequate cardiac output ensures sufficient oxygen and nutrients are delivered to the tissues and organs. One of the most reliable indicators of adequate cardiac output is urine output. A urine output of at least 1 mL/kg/hour, which translates to around 30 mL/hour in a 5-year-old child, indicates adequate perfusion and renal function. In heart failure, decreased cardiac output may lead to decreased renal perfusion, resulting in a decreased urine output, so a stable or increased urine output suggests adequate cardiac output.