Nokea
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.
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The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
Correct Answer: E,D,C,B,A
Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
A client at a psychiatric hospital tells the nurse that he does not want to join the others for dinner in the dining room because he already ate. The nurse is aware this client has been diagnosed with avoidant personality disorder. The best response from the nurse is to
- A. ask the client what would make group dinners more enjoyable so he will participate in the future.
- B. allow the client to skip the group dinner this time only.
- C. ask the client why he ate dinner so early.
- D. state clearly that the client is expected in the dining room and then walk with the client to the dining room.
Correct Answer: D
Rationale: Avoidant personality disorder involves social withdrawal due to fear of rejection. Gently encouraging participation while providing support (walking with the client) promotes socialization without confrontation.
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
- A. Right ventricular hypertrophy
- B. Cardiac dysrhythmia
- C. Left ventricular hypertrophy
- D. Hyperkalemia
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.
A client with psychotic depression is receiving haloperidol (Haldol). Which of the following adverse effects is associated with haloperidol?
- A. Akathisia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathisia, a movement disorder characterized by restlessness, is a common extrapyramidal side effect of haloperidol.
The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to
- A. reduce the client’s diet to 1,500 calorie ADA.
- B. order 3 additional units of NPH insulin at 10 PM.
- C. order an additional 10 units of regular insulin at 8 PM.
- D. eliminate the client’s bedtime snack.
Correct Answer: B
Rationale: dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia