Nokea
What are the priority nursing diagnoses for a client in shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
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What symptoms would a nurse suspect in a client with acoustic neuroma?
- A. Altered facial sensation
- B. Vertigo only when standing
- C. Tinnitus in the unaffected ear
- D. Impaired facial movement when smiling
Correct Answer: A
Rationale: Acoustic neuromas often affect cranial nerve VII, leading to altered facial sensation.
Expected age-related changes of the pulmonary system include:
- A. Significant airway obstruction
- B. Shortness of breath
- C. Development of emphysema
- D. A modest,gradual decline in pulmonary function
Correct Answer: D
Rationale: While lung capacity decreases with age, it typically results in a gradual decline rather than significant obstruction or diseases like emphysema unless other factors (e.g., smoking) are present.
Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)?
- A. Distraction
- B. Corticosteroids
- C. Epidural opioids
- D. Local anesthetics
Correct Answer: D
Rationale: The correct answers are D, Local anesthetics, distraction, and NSAIDs target the transduction stage.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
In planning Mrs. Filbert's care during an acute attack of Meniere disease, it would be most important to
- A. encourage her to discuss her feelings about her illness
- B. keep her siderails up and provide assistance when she is permitted out of bed
- C. instruct her about prescribed dietary modifications
- D. encourage her to walk around her room so that her joints will not get stiff
Correct Answer: C
Rationale: Dietary changes, such as reducing salt intake, play a key role in managing Meniere disease by helping control fluid balance in the inner ear.