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While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- A. Platelet count, prothrombin time, and partial thromboplastin time
- B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- C. Thrombin time, calcium levels, and potassium levels
- D. Fibrinogen level, WBC, and platelet count
Correct Answer: A
Rationale: When monitoring a client for the development of disseminated intravascular coagulation (DIC), it is important to assess key parameters that can indicate abnormal clotting and bleeding tendencies. The platelet count is essential as DIC can lead to thrombocytopenia (low platelet count). Prothrombin time (PT) and partial thromboplastin time (PTT) are coagulation tests that evaluate the extrinsic and intrinsic pathways of blood clotting, respectively. Prolongation of these times can indicate abnormal coagulation processes seen in DIC. Monitoring these parameters allows healthcare providers to assess and manage DIC promptly to prevent further complications.
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what is an appropriate nursing intervention while the child with nephrotic syndrome is confined to bed?
- A. restrain child as necessary.
- B. change position frequently.
- C. discourage parents from holding child.
- D. do passive rang-of-motion exercises once a day.
Correct Answer: B
Rationale: While a child with nephrotic syndrome is confined to bed, changing their position frequently is an appropriate nursing intervention to prevent complications associated with immobility. Constant pressure on certain areas of the body can lead to skin breakdown, discomfort, and decreased circulation which can exacerbate the child's condition. Changing positions frequently helps prevent these complications and promotes circulation and comfort. Restraints should only be used when necessary for the safety of the child or others, passive rang-of-motion exercises should be done more frequently than once a day to prevent contractures, and discouraging parents from holding their child can have negative emotional and psychological effects on the child's well-being.
A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: Walking home in a cold rain can trigger a sickle cell crisis in individuals with sickle cell disease. Exposure to cold temperatures or getting wet can lead to vasoconstriction, causing the blood vessels to narrow and slow down blood flow. This reduced blood flow can increase the likelihood of sickle cells sticking together and blocking blood vessels, leading to pain and tissue damage characteristic of a sickle cell crisis. It is essential for individuals with sickle cell disease to avoid exposure to extreme temperatures, including cold rain, to prevent the onset of a crisis.
Toni's disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above
Correct Answer: D
Rationale: When a patient's disease process involves the sacral plexus, such as in the case of Toni, it is important to assess aspects related to bladder problems, sexual activity, and bowel management. The sacral plexus plays a significant role in controlling functions such as bladder and bowel movements, as well as sexual function. Therefore, a comprehensive assessment including all of these areas is essential to provide holistic care for the patient and address any potential issues related to the sacral plexus involvement.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The nurse should instruct the patient taking propranolol (Inderal) for hypertension to not stop the medication abruptly. Suddenly stopping propranolol can lead to rebound hypertension and potentially dangerous side effects. It is important for the patient to gradually taper off the medication under the guidance of a healthcare provider to avoid complications. Therefore, advising the patient not to stop the medication abruptly is a crucial instruction to ensure their safety and well-being.
The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:
- A. Chronic liver failure.
- B. Pathologic bone fractures.
- C. Acute heart failure.
- D. Hypoxemia.
Correct Answer: B
Rationale: Clients with multiple myeloma are at increased risk for pathologic bone fractures due to the disease's effects on bone tissue. Multiple myeloma is a cancer of plasma cells, a type of white blood cell found in the bone marrow. The growth of abnormal plasma cells weakens the bone structure, leading to bone lesions and an increased risk of fractures. The bone lesions can cause pain, bone deformities, and complications such as hypercalcemia. Therefore, nurses caring for clients with multiple myeloma should prioritize interventions to prevent pathologic bone fractures and manage bone health.