Nokea
What is the priority nursing diagnosis?
- A. Risk for Injury related to seizures
- B. Risk for Other-Directed Violence related to hallucinations
- C. Risk for Situational Low Self-esteem related to police custody
- D. Risk for Nutritional Deficit related to chronic alcohol abuse
Correct Answer: A
Rationale: Seizures pose an immediate risk to the patient's safety.
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When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. In acute renal failure, impaired kidney function can lead to electrolyte imbalances, especially hyperkalemia which can be life-threatening. Monitoring serum potassium levels is crucial to prevent cardiac complications. Serum sodium (A) may be altered, but potassium is more critical. Serum calcium (C) and chloride (D) levels are important but not as directly impacted in acute renal failure compared to potassium.
Which of the following would indicate that Mrs. Filbert understands what you have taught her about her condition?
- A. She delays asking for medication so that she will not become addicted
- B. She asks for medication upon the first indication of an attack
- C. She permits the nurse to perform all of her morning care
- D. She asks her family to assist her at mealtime
Correct Answer: B
Rationale: Promptly seeking medication at the onset of symptoms reflects understanding of how to manage acute attacks effectively.
A student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select one that does not apply)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
Correct Answer: A
Rationale: The correct answer is A: Age. Age is a non-modifiable risk factor for coronary artery disease, meaning it cannot be changed or controlled. Hypertension, obesity, and smoking are modifiable risk factors as they can be managed through lifestyle changes or medical interventions. By controlling blood pressure, maintaining a healthy weight, and quitting smoking, individuals can reduce their risk of developing coronary artery disease. Age, however, is a natural process that cannot be altered. Therefore, focusing on managing modifiable risk factors is crucial in preventing coronary artery disease.
Which physiological response is often associated with surgery-related stress?
- A. Bronchial constriction.
- B. Decreased cortisol levels.
- C. Peripheral vasodilation.
- D. Sodium and water retention.
Correct Answer: D
Rationale: Stress activates the renin-angiotensin-aldosterone system, leading to sodium and water retention.
Mary tells you that she has an undiagnosed case of hypothyroidism. What symptoms would you expect her to present?
- A. Polydipsia and polyphagia.
- B. Fatigue and cold intolerance.
- C. Weight loss and hyperglycemia.
- D. Tachycardia and diarrhea.
Correct Answer: B
Rationale: Hypothyroidism causes fatigue, cold intolerance, and other symptoms of low metabolism.