Nokea
Which of the following conditions is suspected?
- A. Anemia
- B. Rheumatic arthritis
- C. Leukemia
- D. Systematic Lupus Erythematosus (SLE)
Correct Answer: A
Rationale: The correct answer is A: Anemia. Anemia is a common condition characterized by a decrease in red blood cells or hemoglobin levels, leading to symptoms like fatigue and weakness. It is often suspected based on symptoms such as pale skin and shortness of breath. Rheumatic arthritis (B) is a type of arthritis affecting joints, not related to the blood. Leukemia (C) is a type of cancer affecting the blood and bone marrow. Systemic Lupus Erythematosus (SLE) (D) is an autoimmune disease that can affect various organs, not specifically related to blood cell levels. Therefore, based on the symptoms described, anemia is the most likely condition to be suspected.
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Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
- A. Professional physicians’ organizations
- B. State Nurse Practice Acts
- C. The Joint Commission
- D. The Agency for Health Care Research and Quality
Correct Answer: B
Rationale: Correct Answer: B (State Nurse Practice Acts)
Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care.
Summary of Incorrect Choices:
A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice.
C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice.
D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.
In a 28-year-old female client who is being successfully treated for Cushing syndrome, the nurse would expect a decline in:
- A. serum glucose level.
- B. bone mineralization.
- C. hair loss
- D. menstrual flow.
Correct Answer: D
Rationale: The correct answer is D: menstrual flow. In a 28-year-old female with Cushing syndrome, excess cortisol levels can disrupt the menstrual cycle, leading to irregular or absent periods. Successful treatment for Cushing syndrome aims to restore normal cortisol levels, which should result in the resumption of regular menstrual flow. This indicates that the hormonal balance is improving.
Now, let's analyze the other choices:
A: Serum glucose level - While Cushing syndrome can lead to hyperglycemia, successful treatment would aim to normalize glucose levels, not cause a decline.
B: Bone mineralization - Cushing syndrome can cause osteoporosis due to loss of bone density, but successful treatment would help prevent further bone loss rather than decline.
C: Hair loss - Cushing syndrome can cause hair loss, but successful treatment would not necessarily lead to a decline in hair loss as it may take time for hair to regrow.
Therefore, the correct answer is D as it directly relates to the restoration of hormonal
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately.
Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement.
In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.
. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?
- A. High corticotropin and low cortisol levels
- B. high corticotropin and high cortisol levels
- C. Low corticotropin and high cortisol levels
- D. Low corticotropin and low cortisol levels
Correct Answer: B
Rationale: Step-by-step rationale:
1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production.
2. High corticotropin levels would be expected due to the adenoma's overproduction.
3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands.
4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer.
Summary:
- Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma.
- Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma.
- Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.
The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?
- A. Raw fruits
- B. Raw vegetables
- C. Cooked vegetables
- D. Caesar dressing
Correct Answer: C
Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.