Nokea
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
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A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention.
A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis.
B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case.
D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage.
In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient’s toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
- A. hypotension
- B. thick, coarse skin
- C. deposits of adipose tissue in the trunk and dorsocervical area
- D. weight gain in arms and legs
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.