Nokea
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: The correct answer is C: Confusion. Hypernatremia is an electrolyte imbalance characterized by high sodium levels in the blood. Confusion is a common symptom as high sodium levels can affect brain function. Dry skin (A) is more indicative of dehydration, tachycardia (B) is a symptom of various conditions, and pale coloring (D) is not specific to hypernatremia. Confusion is a key indicator that the nurse should assess for when monitoring for hypernatremia.
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Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5’3” in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial.
Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- B. Carcinoma is situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
- D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer: B
Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed.
Step 2: N0 indicates no abnormal regional lymph nodes are involved.
Step 3: M0 signifies no evidence of distant metastasis.
Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report.
Summary:
A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor.
C: Incorrect - TIS already assesses tumor presence, ruling out this option.
D: Incorrect - TIS is not about ascending degrees of distant metastasis.
Of the following information collected during a nursing assessment, which are subjective data?
- A. vomiting, pulse 96
- B. respirations 22, blood pressure 130/80
- C. nausea, abdominal pain
- D. pale skin, thick toenails
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be measured or observed directly. In this case, nausea and abdominal pain are symptoms that can only be described by the patient, making them subjective data. Vomiting, pulse rate, respirations, blood pressure, pale skin, and thick toenails are all objective data, as they can be measured or observed directly by the healthcare provider. Therefore, choice C is the correct answer as it represents subjective data.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: A
Rationale: The correct answer is A. Blood type A is considered the rarest because it is less common in the general population compared to other blood types. The rarity of blood type A is due to the combination of genetic factors that determine blood type. In contrast, blood types B and O are more common in the population, while blood type AB is considered the universal recipient type and is therefore not the rarest. Blood type A is less prevalent, making it the correct answer in this scenario.
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.