Nokea
Which nursing diagnosis is most appropriate for a client with Addison's disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: Addison's disease is a condition characterized by adrenal insufficiency, resulting in a deficiency of aldosterone and cortisol. Without aldosterone, the body is unable to regulate fluid and electrolyte balance properly, leading to sodium loss and potassium retention. This imbalance can result in excessive fluid volume, as the kidneys retain water and sodium. Symptoms of excessive fluid volume in Addison's disease can include edema, weight gain, and hypertension. Therefore, the most appropriate nursing diagnosis for a client with Addison's disease would be Excessive Fluid Volume.
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Newborns are highly susceptible to infection as a result of:
- A. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM).
- B. diminished nonspecific and specific immunity.
- C. increased humoral immunity.
- D. overwhelming anti-inflammatory response.
Correct Answer: B
Rationale: Newborns are highly susceptible to infection due to their diminished nonspecific and specific immunity. Nonspecific immunity includes physical barriers such as intact skin and mucous membranes, as well as components of the innate immune system like phagocytes and complement proteins. Specific immunity refers to the adaptive immune response involving B and T cells. In newborns, both these arms of the immune system are not fully developed or mature, leading to increased susceptibility to infections. Additionally, newborns have lower levels of immunoglobulins like IgA and IgM compared to adults, further contributing to their vulnerability to infections.
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: According to the guidelines by the American Heart Association (AHA), the patient's blood pressure readings of 164/102 and 176/100 on two separate occasions fall in the Stage 2 hypertension category. Stage 2 hypertension is defined as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher. The readings provided are significantly above these thresholds, indicating severe hypertension that requires prompt medical attention and management to reduce the risk of complications such as heart disease, stroke, and kidney damage. It is important for healthcare providers to closely monitor and intervene in cases of Stage 2 hypertension to prevent further health complications.
Barbiturate anticonvulsants are effective in treating all of these seizure types, except:
- A. partial seizures.
- B. febrile seizures.
- C. tonic-clonic seizures.
- D. absence seizures.
Correct Answer: D
Rationale: Barbiturate anticonvulsants are effective in treating partial seizures, tonic-clonic seizures, and febrile seizures. However, they are not considered first-line treatment for absence seizures. Absence seizures typically respond better to other anticonvulsant medications such as ethosuximide or valproic acid. Barbiturates have a sedative effect and can cause drowsiness or cognitive impairment, which may not be ideal for managing absence seizures where maintaining alertness and cognitive function is important.
Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, "We are sick of Mom always sitting with you in the hospital and playing with you. It isn't fair that you get everything and we have to stay with the neighbors." Which is the nurse's best assessment of this situation?
- A. The siblings are immature and probably spoiled.
- B. Jealousy and resentment are common reactions to the illness or hospitalization of a sibling.
- C. Family has ineffective coping mechanisms to deal with chronic illness.
- D. The siblings need to better understand their sister's illness and needs.
Correct Answer: B
Rationale: Jealousy and resentment are common reactions among siblings when one child requires more attention due to illness or hospitalization. It is natural for siblings to feel left out, overlooked, or envious of the extra attention the sick child is receiving. These feelings do not necessarily indicate immaturity or being spoiled but rather a normal emotional response to a challenging family situation. It is important for healthcare providers to recognize and address these feelings to support the entire family in coping with the chronic illness of one of their members.
Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary purpose of administering corticosteroids to this child?
- A. To increase blood pressure
- B. To reduce inflammation
- C. To decrease proteinuria
- D. To prevent infection
Correct Answer: B
Rationale: Corticosteroids are commonly used to reduce inflammation in various conditions, including nephritic syndrome. In nephritic syndrome, there is inflammation in the glomeruli of the kidneys, leading to symptoms such as proteinuria, hematuria, and reduced kidney function. Corticosteroids work by suppressing this inflammatory response, which helps alleviate the symptoms and improve kidney function in patients with nephritic syndrome. Administering corticosteroids to this child aims to reduce the inflammation in the kidneys, thereby improving their condition.