Nokea
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
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A 7-year-old child with type 1 diabetes is admitted with diabetic ketoacidosis. Which intervention should the nurse prioritize?
- A. Administer insulin infusion
- B. Provide oral glucose
- C. Increase dietary carbohydrates
- D. Administer sodium bicarbonate
Correct Answer: A
Rationale: Insulin infusion is the priority in diabetic ketoacidosis to halt ketogenesis and correct hyperglycemia, addressing the underlying metabolic crisis.
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
The nurse is providing care to the client who has received medication therapy with tissue plasminogen activator. Which item should the nurse have available for use as part of standard nursing care for this client?
- A. Flashlight
- B. Pulse oximeter
- C. Suction equipment
- D. Occult blood test strips
Correct Answer: D
Rationale: Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, 'The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments.' The client says, 'I attend therapy for my ankle and I do my exercises three times a day.' Which response should the nurse use with the client?
- A. Show me the exercises that you perform in physical therapy.
- B. You will never heal if you skip the physical therapy sessions.
- C. Your progress sounds fine. Is more physical therapy scheduled?
- D. I see that you missed the last two physical therapy appointments.
Correct Answer: D
Rationale: In the correct option, the nurse employs the therapeutic communication technique of confrontation. Because the client is employing avoidance, the nurse presents the facts according to the medical record to assess the client's perspective without accusing, threatening, or humiliating the client about the missed physical therapy. By confronting, the nurse assists the client with problem-solving. Option 1 is potentially helpful when the client is complying with therapy. In option 2, the nurse provides an opinion and this statement admonishes the client for the behavior. In option 3, the nurse is nontherapeutic in giving approval and is mirroring the client's avoidance and passivity by not dealing directly with the problem of missed appointments.