Nokea
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
- A. Providing the client with a favorite meal for dinner
- B. Asking if the client has allergies to shellfish
- C. Encouraging fluids the evening before the test
- D. Telling the client what to expect during the test
Correct Answer: B
Rationale: Intravenous pyelogram uses iodine-based contrast, which can cause allergic reactions, especially in clients with shellfish/iodine allergies. Identifying allergies is the highest priority for safety.
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A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
- A. Intake and output measurement
- B. Daily weights
- C. Straining of all urine
- D. Administration of O2 therapy
Correct Answer: C
Rationale: Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra.
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
- A. Transient depression
- B. Mild depression
- C. Moderate depression
- D. Severe depression
Correct Answer: D
Rationale: Transient depression manifests as sadness or the 'blues' as seen with everyday disappointments and is not necessarily dysfunctional. Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
The family member of a child scheduled for heart surgery states, 'I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?' The nurse explains that patent ductus arteriosus repair is:
- A. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- C. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
Correct Answer: B
Rationale: Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. Patent ductus arteriosus is a ductus arteriosus that does not close shortly after birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. Percutaneous transluminal coronary angioplasty is a closed-heart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated liver enzymes
Correct Answer: D
Rationale: HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelets) is characterized by elevated liver enzymes reflecting liver damage. Platelet counts are low not elevated and blood glucose and creatinine clearance are not primary features.