Nokea
When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?
- A. A low-grade fever and left lower abdominal pain
- B. Severe headache and sweating all the time
- C. Severe mid-epigastric pain after ingesting a heavy meal
- D. Dull, continuous, right lower quadrant pain and nausea
Correct Answer: C
Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.
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Which client's vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?
- A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
- B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
- C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
- D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.
Correct Answer: C
Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.
What instruction should the nurse provide a pregnant client experiencing heartburn?
- A. Limit fluid intake between meals to prevent stomach over-distension
- B. Take an antacid at bedtime and when symptoms worsen
- C. Maintain an upright position for two hours after eating
- D. Eat small meals throughout the day to avoid a full stomach
Correct Answer: D
Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?
- A. Neutrophils
- B. Lymphocytes
- C. Eosinophils
- D. Monocytes
Correct Answer: C
Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.
When deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factor is most important for the nurse to consider?
- A. Nurse Practice Act of the State
- B. The role of nurses as client advocates
- C. Standards of clinical nursing practice
- D. Personal value system
Correct Answer: B
Rationale: The correct answer is B. The role of nurses as client advocates is crucial when considering the impact of a strike on patient care. Nurses have a responsibility to advocate for their patients' well-being at all times. Choices A, C, and D, although important, are not the most critical factor to consider in this situation. The Nurse Practice Act of the State is essential for guiding nursing practice, standards of clinical nursing practice ensure quality care, and personal values are important; however, the primary focus during a strike should be on the role of nurses as client advocates.
An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client's spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?
- A. Reassure the spouse that the client will be well cared for and provide information about the facility's care practices.
- B. Inform the spouse that care will be adjusted based on the client's condition and needs.
- C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
- D. Suggest that the spouse speak with other family members for reassurance.
Correct Answer: A
Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility's care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.