Nokea
Which of the following should be a priority nursing diagnosis for a client who has had a total laryngectomy?
- A. Risk for impaired skin integrity.
- B. Excess fluid volume.
- C. Ineffective thermoregulation.
- D. Impaired verbal communication.
Correct Answer: D
Rationale: Impaired verbal communication is the priority after a total laryngectomy due to the loss of vocal cords, affecting communication ability.
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A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should the nurse tell the client to report as a potential indication of digoxin toxicity?
- A. Urticaria.
- B. Shortness of breath.
- C. Visual disturbances.
- D. Hypertension.
Correct Answer: C
Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.
The nurse is reviewing the serum laboratory test results for a client with a diagnosis of sickle cell anemia. Which parameter should the nurse anticipate will be elevated?
- A. Sodium
- B. Hemoglobin-S
- C. Hemoglobin A1c
- D. Prothrombin time
Correct Answer: B
Rationale: Sickle cell anemia is a severe anemia that affects African Americans predominantly and is characterized by sickled hemoglobin, or HgbS. The client must have two abnormal genes yielding hemoglobin-S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the client has a less severe form of sickle cell anemia. The remaining options are unrelated to sickle cell anemia.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.
During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as:
- A. 1 on the scale of 1 to 3
- B. 2 on the scale of 1 to 5
- C. 3 on the scale of 0 to 5
- D. 4 on the scale of 0 to 5
Correct Answer: C
Rationale: Muscular strength against gravity but not resistance is graded as 3 on the 0-5 scale, indicating fair strength.