Nokea
Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.
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A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends's behavior shows that they aren't true friends
Correct Answer: C
Rationale: It is important for the nurse to listen and show interest as the client expresses their feelings in this situation. The client's emotional distress is a valid response to feeling abandoned by friends and family during a difficult time. By providing a supportive and empathetic presence, the nurse can help the client feel valued and understood, promoting emotional well-being and potentially increasing the client's sense of comfort and trust in the healthcare setting. This approach validates the client's feelings and fosters therapeutic communication, which is crucial in providing holistic care to individuals with complex health needs such as AIDS and Pneumocystis carinii pneumonia. It is essential to acknowledge and address the client's emotional needs in addition to their physical care.
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.
\What should the nurse teach an older client with TIA?
- A. Not to worry about the symptoms that are part of the normal aging process
- B. To admit oneself to a rehabilitation center or a nursing home for rehabilitation
- C. To comply with the medication regimen
- D. To observe any changes in the nails and skin
Correct Answer: C
Rationale: The nurse should teach an older client with a transient ischemic attack (TIA) to comply with the medication regimen. TIA is a warning sign of a potential stroke, and medication compliance is crucial in reducing the risk of a future stroke. Medications prescribed after a TIA may include blood thinners, antiplatelet agents, antihypertensives, and cholesterol-lowering drugs. It is essential for the client to take these medications as directed by their healthcare provider to prevent further cardiovascular events. Compliance with the medication regimen plays a significant role in managing the risk factors associated with stroke and promoting long-term health and well-being.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: C
Rationale: Lymphangiography is a procedure in which a contrast dye is injected into the lymphatic vessels to help identify abnormalities. One harmless, temporary change that a client may experience after lymphangiography is the passing of bluish urine. This happens as a result of the contrast dye being excreted in the urine, causing it to temporarily change color. It is important for the nurse to inform the client about this possibility to prevent unnecessary worry or concern after the procedure. No concerns are associated with purplish stools, redness of the upper part of the feet, or coldness of the soles after a lymphangiography.
The MOST common cause of sleeping difficulty in the first 2 months of life is
- A. gastro-esophageal reflux
- B. colic
- C. formula intolerance
- D. developmentally self-resolving sleeping behavior
Correct Answer: B
Rationale: Colic is a frequent cause of sleep difficulties in young infants.