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: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
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Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR’s doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure.
Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state.
Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure.
Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: The correct answer is C because antihistamines can suppress the immune response that the skin test is designed to detect, leading to false negative results. By inhibiting the body's allergic response, antihistamines can mask the presence of an allergy, giving the false impression that the individual is not allergic to a particular substance. This can lead to misdiagnosis and improper treatment. Choices A, B, and D are incorrect because antihistamines do not affect bleeding, aggravate allergic reactions, or cause wheezing in the context of a skin test.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Mammography
- C. Fine needle aspiration
- D. Chest x-ray
Correct Answer: C
Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.”
Correct Answer: B
Rationale: The correct answer is B. Polymyositis can affect muscles involved in swallowing, leading to aspiration risk. Therefore, it's crucial for the client to exhibit no signs or symptoms of aspiration. Choice A is unrelated to polymyositis. Choice C involves issues with muscle weakness rather than aspiration risk. Choice D relates to cognitive function, not a common issue with polymyositis.
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: C
Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.