Nokea
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
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During starvation, the body slows metabolic processes and growth to minimize the need for nutrients. With the rapid reinstitution of feeding after starvation refeeding syndrome may occur. Of the following, the major changes that may occur with refeeding syndrome typically affect
- A. electrolytes
- B. serum proteins
- C. hormones
- D. liver enzymes
Correct Answer: A
Rationale: Refeeding syndrome primarily affects electrolytes, particularly phosphorus, potassium, and magnesium, which can become dangerously depleted due to rapid shifts in metabolism.
In embryonic period, all are true EXCEPT
- A. formation of ectoderm by 8 days
- B. formation of mesoderm by 10 weeks
- C. formation of endoderm by 3 cm crown-rump length
- D. formation of human embryo is about 6 weeks
Correct Answer: D
Rationale: The formation of the human embryo is completed by 8 weeks, not 6 weeks.
Mr. Mendres asks Nurse Rose what causes peptic ulcer to develop. Nurse Rose responds that recent research indicates that peptic ulcers are the result of which of the following?
- A. genetic defect in the gastric mucosa
- B. helicobacter pylori infection
- C. high fat diet
- D. work related stress
Correct Answer: B
Rationale: Recent research suggests that the majority of peptic ulcers are caused by an infection with Helicobacter pylori bacteria. This bacterium weakens the protective mucous coating of the stomach and duodenum, leading to damage from stomach acid. Genetic defects in the gastric mucosa, high fat diet, and work-related stress may exacerbate the condition but are not the primary cause of peptic ulcers. Therefore, the most likely cause based on current understanding is H. pylori infection.
Biopsy is not usually performed for a child with suspicion of Wilms tumor EXCEPT
- A. age of 2-3 year
- B. signs of inflammation or infection
- C. significant lymph node enlargement radiologically
- D. intratumoral calcification radiologically
Correct Answer: E
Rationale: Presence of intratumoral calcifications may warrant biopsy to rule out other diagnoses.
A 68-year old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
- A. Diabetes mellitus
- B. Hypoparathyroidism
- C. Diabetes insipidus
- D. Hyperparathyroidism
Correct Answer: D
Rationale: The symptoms described in the client, such as increased urination, anorexia, weakness, irritability, depression, and bone pain suggest hyperparathyroidism. In hyperparathyroidism, excess parathyroid hormone (PTH) is released, leading to increased calcium levels in the blood. This results in symptoms such as increased thirst and urination (polyuria), anorexia, weakness, irritability, depression, and bone pain. The bone pain in hyperparathyroidism can be severe and interfere with the client's ability to go outdoors. It is essential to consider hyperparathyroidism as a potential cause of these symptoms in the 68-year-old client and further diagnostic evaluations should be conducted to confirm the diagnosis.