Nokea
The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.47 (alkaline) with low PCO2 (28) indicates respiratory alkalosis, likely from hyperventilation due to brain injury. Normal HCO3 rules out metabolic causes.
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Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
- A. Report the findings to the physician
- B. Assist the client to do range of motion exercises
- C. Check the client's potassium level
- D. Administer the as-needed dose of phenytoin (Dilantin)
Correct Answer: A
Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which food should the client avoid?
- A. Shellfish
- B. Apples
- C. Carrots
- D. Rice
Correct Answer: A
Rationale: Shellfish are high in purines, which increase uric acid levels, worsening gout. Apples, carrots, and rice are low-purine foods and safe.
The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
- A. High fever, tachycardia, stupor, renal failure
- B. Lip smacking, chewing, blinking, lateral jaw movements
- C. Photosensitivity, orthostatic hypotension, dry mouth
- D. Constipation, blurred vision, drowsiness
Correct Answer: B
Rationale: These symptoms are found in clients with tardive dyskinesia.
Which of the following nursing diagnoses is of highest priority for the patient with hypothyroidism?
- A. Impaired physical mobility
- B. Hypothermia
- C. Disturbed thought processes
- D. Decreased cardiac output
Correct Answer: D
Rationale: Hypothyroidism reduces metabolic rate potentially decreasing cardiac output which can lead to life-threatening complications like heart failure. While hypothermia and other diagnoses are relevant decreased cardiac output is the most critical.