Nokea
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.
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Select the 4 findings that require immediate follow up
- A. Hallucinations
- B. Heart rate
- C. Sleep patterns
- D. Skin turgor
- E. Hygiene
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Hallucinations (A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (B) could signify a cardiac problem. Disrupted sleep patterns (C) may indicate underlying health conditions. Reduced skin turgor (D) can signal dehydration or malnutrition. Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
Which statement indicates understanding of the teaching?
- A. A transcutaneous electrical nerve stimulator will help with pelvic pressure
- B. I can use my ultrasound picture as a focal point during contractions
- C. Breathing techniques can help me stay relaxed during contractions
- D. Changing positions frequently can reduce my discomfort
- E. A warm shower or bath may help ease my labor pain
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of the teaching on coping strategies during labor. Breathing techniques are commonly taught to help manage pain and promote relaxation during contractions. This choice aligns with established labor preparation methods. Other choices lack direct relevance to labor pain management. A focuses on a specific device rather than coping mechanisms. B focuses on a visual aid, which may not address pain management directly. D mentions changing positions, which is beneficial but not as directly related to relaxation techniques. E mentions a warm shower or bath, which can help with pain relief but doesn't specifically address relaxation techniques for coping with contractions.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
- A. Mania
- B. Delirium
- C. Catatonia
- D. Magical thinking
- E. Euphoric mood
- F. Hypervigilance
- G. Panic disorder
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness. Therefore, the combination of mania and euphoric mood is indicative of a manic episode. Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.