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When monitoring for hypernatremia, the nurse should assess the client for:
- A. Dry skin
- B. Tachycardia
- C. Confusion
- D. Pale coloring
Correct Answer: C
Rationale: Hypernatremia is a condition characterized by high levels of sodium in the blood. When monitoring for hypernatremia, the nurse should assess the client for signs of neurologic impairment, such as confusion. This is because hypernatremia can lead to changes in mental status due to the hyperosmolarity of the blood affecting brain function. Assessing for confusion is crucial in identifying and managing hypernatremia promptly to prevent further complications. Dry skin, tachycardia, and pale coloring are not specific manifestations of hypernatremia and are less likely to be directly related to this electrolyte imbalance.
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A 5-year-old child, recently diagnosed with ileocecal Burkitt lymphoma; lab investigations reveal: serum uric acid 12 mg/dl, serum sodium, 145 meq/dl; serum potassium, 4.5 meq/dl; serum phosphate 4.4 meq/dl; serum calcium, 8.9 mg/dl; blood urea, 22 mg/dl; serum creatinine, 0.8 mg/dl. Of the following, the MOST effective treatment is
- A. excessive hydration
- B. sodium bicarbonate
- C. xanthine oxidase inhibitor
- D. recombinant urate oxidase
Correct Answer: D
Rationale: Recombinant urate oxidase (rasburicase) effectively lowers uric acid levels in cases of tumor lysis syndrome.
A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?
- A. To determine the severity of the disorder
- B. To identify signs of fluid retention
- C. To determine the location of discomfort
- D. To determine clients response to therapy
Correct Answer: A
Rationale: Evaluating the client's BUN, creatinine, and serum electrolyte levels when being treated for acute pyelonephritis is crucial in determining the severity of the disorder. BUN and creatinine levels are indicators of renal function, where elevated levels may suggest impaired kidney function due to inflammation in the kidneys from pyelonephritis. Abnormal electrolyte levels, such as potassium and sodium, may also reflect the impact of the infection on renal function. Therefore, monitoring these test results helps healthcare providers assess how well the kidneys are functioning and the severity of the pyelonephritis to guide appropriate treatment decisions.
The neurologist tests the 4th and 6th cranial nerves together by having a patient do which of the following?
- A. Turn his head to the right and left
- B. Say "ahhh"
- C. Identify whispering in his ears
- D. Follow his finger with his eyes
Correct Answer: D
Rationale: The neurologist tests the 4th and 6th cranial nerves together by having a patient follow his finger with his eyes. The 4th cranial nerve (trochlear nerve) innervates the superior oblique muscle, which primarily moves the eye downward and outward. The 6th cranial nerve (abducens nerve) innervates the lateral rectus muscle, which primarily moves the eye laterally. Testing these cranial nerves simultaneously by asking the patient to follow the neurologist's finger helps assess the coordination and function of both of these nerves, which are important for eye movement control.
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.
Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:
- A. 12 months.
- B. 15 months.
- C. 10 months.
- D. 14 months.
Correct Answer: A
Rationale: The Denver Developmental Screening Test states that the median age for walking is around 12 months. This means that about half of all typically developing children will begin to walk by this age. It is important to note that there is a wide range of normal development, and not all children will hit these milestones at the same time. If Cherry's 11-month-old daughter, Elizabeth, is not yet walking, it does not necessarily indicate a developmental delay as long as she is meeting other milestones within a reasonable timeframe.