Nokea
While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
- A. It promotes the clients compliance with therapy
- B. It minimizes the chances of adverse effects
- C. It promotes a strict food and fluid intake habit
- D. It raises the self esteem of the client
Correct Answer: A
Rationale: It is essential for a nurse to ensure that the client is actively involved in the development of the plan for proportionate distribution of restricted fluid volumes because it promotes the client's compliance with therapy. When the client participates in creating the plan, they are more likely to understand the importance of following it and be motivated to adhere to the recommended fluid restrictions. This active involvement fosters a sense of ownership and responsibility, leading to better treatment outcomes and improved overall health.
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Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hypertrophied tonsils
- C. Hemorrhage in the tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The presence of white patches on the tonsils is a visual sign that may be revealed by a visual examination in a client with a tonsillar infection caused by group A streptococci. These white patches are known as exudates and can be a characteristic feature of streptococcal tonsillitis. These exudates may range in appearance from small white spots to larger patches that cover the tonsils. Additionally, other signs commonly associated with streptococcal tonsillitis may include swollen and red tonsils, fever, sore throat, and sometimes swollen lymph nodes in the neck. It is important to note that definitive diagnosis often requires laboratory testing such as a rapid strep test or throat culture to confirm the presence of group A streptococci.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
- A. It usually resolves in 3-6 weeks
- B. It doesn't cross the cranial suture line
- C. It's a collection of blood between the skull and the periosteum
- D. It involves swelling of tissue over the presenting part of the presenting head
Correct Answer: D
Rationale: Caput succedaneum is a condition characterized by the swelling of tissue over the presenting part of the infant's head during delivery. It is commonly a result of prolonged labor or vacuum extraction. Unlike cephalohematoma, caput succedaneum does cross the cranial suture lines. This condition typically resolves within a few days to a week after birth without intervention. It is important to monitor the infant for any complications or signs of infection during the resolution process.
A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
- A. A rapid, thready pulse
- B. Decreased peristalsis .
- C. Respiratory congestion
- D. An increased in temperature
Correct Answer: C
Rationale: Following a paracentesis procedure where a large amount of ascitic fluid is removed, there is a risk of developing a fluid shift and a potential complication known as "paracentesis-induced circulatory dysfunction" (PICD). This may cause a sudden increase in central blood volume due to rapid re-distribution of fluid, leading to respiratory congestion, dyspnea, and hypoxemia. Therefore, it is crucial for the nurse to monitor the client closely for signs of respiratory distress or congestion immediately after the procedure to prevent any respiratory complications. A rapid, thready pulse (choice A) may indicate hypovolemia, but it is not the most important immediate concern in this case. Decreased peristalsis (choice B) and an increased temperature (choice D) are not typically associated with the immediate post-paracentesis period and are therefore lower priorities compared to monitoring for signs of respiratory congestion.
When caring for a client, whose being treated for hyperthyroidism, it's important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client's periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: When caring for a client with hyperthyroidism, it is important to monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy. Treatment for hyperthyroidism often involves thyroid replacement therapy to restore the balance of thyroid hormones in the body. Monitoring for signs and symptoms of overmedication or undermedication is crucial to ensure the client's health and well-being. Restlessness, sweating, and weight loss can be indicators of an imbalance in thyroid hormone levels and may require adjustments in medication dosage. Regular monitoring and communication with healthcare providers are essential in managing the client's condition effectively.
A patient is scheduled for an MRI and asks what to expect. Which of the following responses by the nurse is best?
- A. "It is the measurement of muscle contraction after stimulation by tiny needle electrodes."
- B. "Electrodes will be placed on your scalp to measure activity of the brain."
- C. "A scan of the brain will be done after injection of radioisotope."
- D. "It is a noninvasive test that uses magnetic energy to visualize internal parts."
Correct Answer: D
Rationale: The best response by the nurse in this scenario is option D: "It is a noninvasive test that uses magnetic energy to visualize internal parts." This response provides a clear and accurate description of what an MRI (Magnetic Resonance Imaging) involves. An MRI is a diagnostic test that uses a powerful magnetic field, radio waves, and a computer to create detailed images of the internal structures of the body. It is noninvasive, meaning there are no needles, electrodes, or injections involved. By explaining the procedure in a simple and understandable way, the nurse can help alleviate any anxiety or concerns the patient may have about the upcoming MRI.