Nokea
Which of the following is a nursing diagnosis that reflects some unexpected response to a therapy?
- A. Episiotomy extension related to a forceps delivery
- B. Respiratory depression related to NSAIDs
- C. Hemothorax related to a latex allergy
- D. All of the above
Correct Answer: D
Rationale: All listed diagnoses reflect unexpected responses to therapies (forceps delivery, NSAIDs, latex exposure), qualifying as adverse reactions.
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The parents of a child with mumps express concern that their child will develop orchitis as a result of having mumps. What characteristic of this complication should the nurse discuss with the parents?
- A. Fever
- B. Facial swelling
- C. Swollen glands
- D. Difficulty urinating
Correct Answer: A
Rationale: Unilateral orchitis occurs more frequently than bilateral orchitis. About 1 week after the appearance of parotitis, there is an abrupt onset of testicular pain, tenderness, fever, chills, headache, and vomiting. The affected testicle becomes red, swollen, and tender. Atrophy, resulting in sterility, occurs only in a small number of cases. Facial swelling and swollen glands normally occur in mumps. Difficulty urinating is not a sign of this complication.
The client with a burn injury is assessed using the 'rule of nines' to determine which of the following?
- A. Amount of body surface area burned.
- B. Rehabilitation needs.
- C. Respiratory needs.
- D. Type of intravenous fluids required.
Correct Answer: A
Rationale: The rule of nines estimates the percentage of body surface area burned to guide treatment.
Which of the following abnormal serum chemistry results is a client with cirrhosis who has developed ascites likely to have?
- A. Decreased aspartate aminotransferase.
- B. Hypoalbuminemia.
- C. Hyperkalemia.
- D. Decreased alanine aminotransferase.
Correct Answer: B
Rationale: Cirrhosis impairs liver protein synthesis, leading to hypoalbuminemia, which causes ascites due to decreased oncotic pressure.
A client with a history of systemic lupus erythematosus (SLE) reports joint pain and fatigue. Which intervention should the nurse prioritize?
- A. Administer analgesics as ordered
- B. Encourage high-impact exercise
- C. Apply cold packs to joints
- D. Restrict fluid intake
Correct Answer: A
Rationale: Administering analgesics addresses joint pain, a common SLE symptom, improving comfort and quality of life.
A client with a fractured femur is placed in skeletal traction. The nurse should assess the client for which of the following complications?
- A. Pressure ulcers.
- B. Deep vein thrombosis.
- C. Hypovolemia.
- D. Infection at the pin sites.
Correct Answer: B,D
Rationale: Skeletal traction increases the risk of deep vein thrombosis due to immobility and infection at pin sites due to skin penetration.