Nokea
Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)?
- A. Fluid retention.
- B. Pain.
- C. Peripheral edema.
- D. Hunger.
Correct Answer: B
Rationale: Pain, particularly abdominal, is a common symptom in addisonian crisis due to electrolyte imbalances and hypotension.
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The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
If the client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
- A. Review the negative effects of smoking on the body.
- B. Discuss the effects of passive smoking on environmental pollution.
- C. Establish the client's daily smoking pattern.
- D. Explain how smoking worsens high blood pressure.
Correct Answer: C
Rationale: Establishing the daily smoking pattern identifies triggers and habits, forming the basis for a tailored cessation plan.
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
- A. Oliguria.
- B. Bradycardia.
- C. Elevated blood pressure.
- D. Fever.
Correct Answer: A
Rationale: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.
Which intervention is most effective for a client with MS-related vision impairment?
- A. Provide bright lighting.
- B. Use large-print materials.
- C. Limit visual activities.
- D. Wear dark glasses.
Correct Answer: B
Rationale: Large-print materials support clients with MS-related vision impairment by improving readability.