Nokea
Which of the following is the appropriate nursing diagnosis?
- A. Fluid volume deficit R/T furrow tongue
- B. Fluid volume deficit R/T uncontrolled vomiting
- C. Dehydration R/T subnormal body temperature
- D. Dehydration R/T incessant vomiting
Correct Answer: B
Rationale: The appropriate nursing diagnosis is Fluid volume deficit R/T uncontrolled vomiting. This diagnosis is the most specific and directly related to the issue of vomiting causing a loss of fluids, leading to a deficit in fluid volume. Uncontrolled vomiting can result in a significant loss of fluids and electrolytes, which can lead to dehydration. It is important to address the root cause of the fluid volume deficit, which in this case is the uncontrolled vomiting. The other options may not directly address the primary issue of fluid loss due to vomiting.
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A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
- A. 1 mg/kg of body weight
- B. 5 mg/70kg of body weight
- C. 5 mg/kg of body weight
- D. 10mg/70kg of body weight
Correct Answer: C
Rationale: When calculating the appropriate dose of morphine for a client, the nurse should consider the client's body weight. The most commonly used formula for calculating the appropriate dose of morphine is 0.1 to 0.2 mg/kg of body weight for hourly dosing or 2.5 to 10 mg/kg/day for continuous infusions.
Cystic fibrosis most often affects multiple systems of the body. The primary factor responsible for possible multiple clinical manifestations is which of the following?
- A. Hyperactivity of sweat glands
- B. Hypoactivity of parasympathetic nervous system
- C. Sweat chloride test >60 mEq/L
- D. Increased viscosity resulting in mucous gland secretions
Correct Answer: D
Rationale: Cystic fibrosis (CF) is an inherited genetic disorder caused by mutations in the CFTR gene, leading to the production of thick, sticky mucus. This increased viscosity affects various organs and systems in the body, causing multiple clinical manifestations. The abnormal secretions block the airways in the lungs, leading to recurrent lung infections, breathing difficulties, and ultimately respiratory failure. In the digestive system, the thick mucus blocks the pancreatic ducts, impairing the release of digestive enzymes, which can result in malabsorption and malnutrition. Additionally, the thick secretions can affect the liver, leading to complications like liver disease. Therefore, the primary factor responsible for the multiple clinical manifestations in cystic fibrosis is the increased viscosity of the mucous gland secretions, which impacts various systems in the body.
Which behaviors by the nurse indicate a therapeutic relationship with children and families? (Select all that apply.)
- A. Spending off-duty time with children and families
- B. Asking questions if families are not participating in the care
- C. Clarifying information for families
- D. Buying toys for a hospitalized child
Correct Answer: B
Rationale: Asking questions if families are not participating in the care is a behavior that indicates a therapeutic relationship with children and families. It shows the nurse's concern and interest in understanding the family's perspectives and addressing any barriers to participation.
The mother of a child with a congenital cardiac defect asks the nurse why her child squats after exertion. The nurse should reply that this position:
- A. Reduces muscle aches
- B. Increases cardiac efficiency
- C. Enhances the pull of gravity
- D. Decreases blood volume in the extremities
Correct Answer: B
Rationale: The position of squatting after exertion increases cardiac efficiency in children with congenital cardiac defects, specifically those with Tetralogy of Fallot. By squatting, the child decreases systemic vascular resistance and increases systemic venous return, which helps to enhance cardiac output by improving blood flow to the lungs. This position allows for better oxygenation of the blood and helps alleviate cyanosis in children with Tetralogy of Fallot.
The nurse is aware that the following laboratory values support a diagnosis of pyelonephritis?
- A. Myoglobinuria
- B. Ketonuria
- C. Pyuria
- D. Low white blood cell (WBC) count
Correct Answer: C
Rationale: Pyelonephritis is a bacterial infection of the kidney. One of the key indicators of pyelonephritis is the presence of pyuria, which refers to white blood cells in the urine. White blood cells in the urine suggest inflammation and infection in the urinary tract, particularly in the kidneys. Therefore, the presence of pyuria supports a diagnosis of pyelonephritis. Myoglobinuria (choice A) is the presence of myoglobin in the urine and is associated with muscle breakdown, not specifically with pyelonephritis. Ketonuria (choice B) refers to the presence of ketones in the urine and may be seen in conditions such as diabetic ketoacidosis. A low white blood cell count (choice D) is not typically associated with pyelonephritis, as an infection would generally result in an elevated white blood cell count in response to the infection.