Nokea
To monitor the severity of a patient's heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?
- A. Weight
- B. Appetite
- C. Calorie count
- D. Abdominal girth
Correct Answer: A
Rationale: Monitoring a patient's weight is a crucial assessment in heart failure management. Sudden weight gain could indicate fluid retention, which is a common sign of worsening heart failure. By regularly monitoring the patient's weight, the nurse can detect early signs of fluid buildup and adjust the treatment plan accordingly. Weight monitoring is a simple yet effective way to assess the severity of heart failure and prevent complications. The other options (B. Appetite, C. Calorie count, D. Abdominal girth) are not as directly related to monitoring heart failure severity as weight measurement.
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At a public health fair, the nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:
- A. Fever.
- B. Nipple discharge and a breast nodule.
- C. Breast changes during menstruation.
- D. Fever and erythema of the breast.
Correct Answer: B
Rationale: Possible signs of breast cancer include nipple discharge (especially if it is bloody) and a breast nodule or lump that can be felt. It is important to note any changes in the breasts and report them to a healthcare provider for evaluation. Fever, breast changes during menstruation, and erythema of the breast are not typically associated with breast cancer. It is essential for women to perform regular breast self-exams and seek medical attention if they notice any unusual changes in their breast tissue.
Metabolic derangement secondary to tumor lysis syndrome in children includes all the following EXCEPT
- A. hyperuricemia
- B. hypernatremia
- C. hyperkalemia
- D. hyperphosphatemia
Correct Answer: B
Rationale: Hypernatremia is not typically associated with tumor lysis syndrome, whereas hyperuricemia, hyperkalemia, and hyperphosphatemia are common.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.
A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client's hands. based on the client's history and the nurse's understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The signs of irritability, irrational behavior, and visible tremors in the hands observed in the 45-year old female diabetic suggest hypoglycemia. Hypoglycemia occurs when blood sugar levels drop below normal levels, causing the body and brain to receive inadequate fuel. This leads to symptoms like irritability, irrational behavior, and tremors, which are signs of the brain not receiving enough glucose for proper functioning. In diabetic patients, particularly those on medications like insulin or certain oral hypoglycemic agents, hypoglycemia can occur if they take too much medication, skip meals, or engage in excessive physical activity without adjusting their treatment regimen. Immediate treatment for hypoglycemia usually involves consuming a rapid source of sugar, such as glucose tablets, juice, or candy, to quickly raise blood sugar levels back to normal range.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
- A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue.
- B. The nurse should help the mother restrain the child to prevent him from injuring himself.
- C. The nurse should call the operator to page for seizure assistance.
- D. The nurse should clear the area and position the client safely.
Correct Answer: D
Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.