Nokea
Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?
- A. Skin turgor.
- B. Temperature.
- C. Thirst.
- D. Daily weight.
Correct Answer: D
Rationale: Daily weight reflects fluid balance, which is influenced by glucocorticoid and mineralocorticoid replacement in Addison's disease.
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What should the nurse do first for a client with a suspected spinal cord injury?
- A. Immobilize the spine.
- B. Administer pain medication.
- C. Check motor function.
- D. Obtain a CT scan.
Correct Answer: A
Rationale: Immobilizing the spine is the first priority to prevent further injury in a suspected spinal cord injury.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.
When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
- A. Bleeding tendencies.
- B. Intake and output.
- C. Peripheral sensation.
- D. Bowel function.
Correct Answer: A
Rationale: Aplastic anemia causes pancytopenia, including thrombocytopenia, which increases the risk of bleeding. The nurse should assess for bleeding tendencies, such as petechiae, bruising, or mucosal bleeding. Intake/output, sensation, and bowel function are not primarily affected.
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
- A. Bowel obstruction
- B. Paralytic ileus
- C. Peritonitis
- D. Wound dehiscence
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.