Nokea
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.
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A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The correct answer is A: Postural hypotension. This condition is characterized by a drop in blood pressure upon standing, leading to dizziness. The client's symptoms of dizziness upon standing, along with nosebleeds and blurred vision, are indicative of low blood pressure. Postural hypertension (B) is not a recognized medical condition; White coat hypertension (C) refers to elevated blood pressure readings in a medical setting due to anxiety; White coat hypotension (D) is not a recognized medical condition.
A nursing intervention for anemia is:
- A. Medical therapy
- B. High protein, vitamin and iron diet
- C. Fluid therapy
- D. Chemotherapy
Correct Answer: B
Rationale: The correct answer is B, a high protein, vitamin, and iron diet, as it directly addresses the nutritional deficiencies associated with anemia. Proteins aid in the production of red blood cells, while iron and vitamins are essential for hemoglobin synthesis. Medical therapy (A) typically involves medications or blood transfusions, not dietary changes. Fluid therapy (C) may be used for certain types of anemia, but it is not a primary intervention. Chemotherapy (D) is not indicated for the treatment of anemia, as it is used for cancer treatment. Therefore, choice B is the most appropriate intervention for anemia.
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?
- A. Sharp pain in the knee
- B. Small bloody drainage on dressing
- C. Temperature of 102 degrees F
- D. Pulse rate of 90 beats per minute
Correct Answer: A
Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain.
B: Small bloody drainage is an objective cue that can be observed and measured by the nurse.
C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer.
D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter.
In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.
A male client recently underwent a surgical procedure for a malignant tumor. As a result of the surgery, his urine is diverted to a stomal pouch. What should the nurse suggest so that he remains odor free.
- A. Eating spicy foods
- B. Drinking cranberry juice
- C. Eating eggs, asparagus, or cheese
- D. Drinking tea, coffee and colas
Correct Answer: B
Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because:
A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor.
C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor.
D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.