Nokea
Which of the following is a metabolic, life-threatening adverse reaction to general anesthesia?
- A. hypothermia
- B. hyperthermia
- C. hypoglycemia
- D. hyperglycemia
Correct Answer: B
Rationale: Malignant hyperthermia is a life-threatening reaction to general anesthesia, characterized by rapid temperature increase due to muscle hypermetabolism.
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A client has recently lost her best friend to cancer. The client tells the nurse, 'I'm very sad about the loss of my friend.' Which of the following responses by the nurse is the most appropriate?
- A. I lost my best friend two years ago, but I feel better now.
- B. It's important for you to keep busy.
- C. Why do you feel this way?
- D. It's normal to feel loss. Tell me about your friend.
Correct Answer: D
Rationale: This response validates the client’s grief and encourages her to share, promoting therapeutic communication and emotional support.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: A pain scale provides a reliable, subjective measure of pain.
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?
- A. justice
- B. fidelity
- C. autonomy
- D. beneficence
Correct Answer: C
Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.
The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.