Nokea
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. Providing pain relief
- C. Preventing infection
- D. O2 therapy
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
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When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?
- A. Small round or oval reddish brown macules scattered over the entire body
- B. Scattered clusters of macules, papules, and vesicles over the body
- C. Bright red appearance of the palmar surface of the hands
- D. Reddened butterfly shaped rash over the cheeks and nose
Correct Answer: D
Rationale: The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. Palmar redness is seen in clients with cirrhosis of the liver. The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.
The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client's vision?
- A. Temporal lobe
- B. Frontal lobe
- C. Occipital lobe
- D. Parietal lobe
Correct Answer: C
Rationale: The occipital lobe processes visual information. A cerebral vascular accident affecting this area can cause visual deficits such as hemianopia or visual agnosia. The temporal lobe manages auditory and memory functions, the frontal lobe controls behavior and motor skills, and the parietal lobe handles sensory integration.
The nurse is teaching a client with a new colostomy about dietary management. Which food should the client avoid to reduce odor?
- A. Broccoli
- B. Rice
- C. Chicken
- D. Yogurt
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, increases colostomy odor due to sulfur compounds. Rice (B), chicken (C), and yogurt (D) are odor-neutral and appropriate.
A client with a history of a thyroidectomy is receiving Calcitonin (Miacalcin). The nurse should monitor the client for:
- A. Hypocalcemia
- B. Hyperglycemia
- C. Hypotension
- D. Weight gain
Correct Answer: A
Rationale: Calcitonin lowers serum calcium, risking hypocalcemia, requiring monitoring for symptoms like tingling. Hyperglycemia, hypotension, and weight gain are not primary concerns.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.