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Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
- A. To determine the clients response to the therapy
- B. To flush out the infectious microorganisms from the urinary tract
- C. To determine the location of discomfort
- D. To detect any evidence of changes#
Correct Answer: B
Rationale: A nurse measures the intake and output and recommends a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis primarily to help flush out the infectious microorganisms from the urinary tract. Pyelonephritis is a bacterial infection of the kidneys and urinary tract, and increasing fluid intake can help dilute the urine and increase urine output, which may help wash out and eliminate the infectious microorganisms causing the infection. Adequate hydration also helps the kidneys function optimally in eliminating waste and toxins from the body. Therefore, maintaining a high fluid intake is crucial in the management of pyelonephritis to support the body's natural defense mechanisms and aid in recovery.
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Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: Compartment syndrome is a serious condition that results from increased pressure within a closed anatomical space (compartment), leading to decreased circulation to local neuromuscular structures. In the case of a casted elbow, if compartment syndrome is left untreated and persists for more than 24 hours, irreversible damage can occur. This is due to the compromised blood flow causing tissue ischemia, which can lead to permanent nerve and muscle damage. Therefore, it is crucial for healthcare providers to monitor for signs and symptoms of compartment syndrome and intervene promptly to prevent long-term complications.
Which is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats?
- A. Social isolation
- B. Level of stress
- C. Degree of depression
- D. Desire to punish others
Correct Answer: D
Rationale: The most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats is the desire to punish others. Individuals who commit suicide often exhibit behaviors or thought patterns indicating a desire to cause harm or guilt to others. This desire to punish others may drive them to take their own lives as a way to make others feel responsible or suffer the consequences of their actions. On the other hand, individuals who make suicidal attempts or threats may not have the same level of intent to harm others through their actions, and their motivations may stem from different underlying issues such as social isolation, stress, or depression. Therefore, the desire to punish others is a crucial factor that sets those who commit suicide apart from those who make attempts or threats.
A nurse needs to assess a client who is undergoing urinary diversion. Which of the ff assessment is essential for the client?
- A. The client's knowledge about the effects of the surgery on his sexual function
- B. The clients medical history of allergy to iodine or seafood
- C. The clients knowledge about the effects of the surgery on his nervous control
- D. The clients occupational and environmental health hazards
Correct Answer: C
Rationale: The essential assessment for a client undergoing urinary diversion is the client's knowledge about the effects of the surgery on his nervous control. Urinary diversion is a surgical procedure that involves redirecting urine flow from the bladder to a new exit point in the body due to bladder cancer, birth defects, or other medical conditions. Understanding the effects of the surgery on nervous control is crucial as it can impact the client's ability to control urination and bowel movements post-surgery. Educating the client about these effects will help in managing expectations and in planning for any necessary adjustments to their lifestyle and daily routine. It is important for the nurse to assess the client's level of understanding and provide appropriate education and support regarding nervous control changes that may result from the procedure.
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient's status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.
The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. What is the preterm newborn at increased risk of due to the mechanical ventilation?
- A. Alveolar rupture
- B. Meconium aspiration
- C. Transient tachypnea
- D. Retractions and nasal flaring
Correct Answer: A
Rationale: Preterm newborns who require mechanical ventilation are at increased risk of developing alveolar rupture. The pressure from mechanical ventilation can lead to overdistension of the alveoli, causing damage to their delicate structure. This can result in the rupture of the alveolar walls, leading to a condition known as pulmonary interstitial emphysema. Alveolar rupture can contribute to the development of other complications such as pneumothorax and air leaks, which can further compromise the newborn's respiratory status. Therefore, close monitoring and adjustment of ventilation parameters are crucial in the care of preterm newborns on mechanical ventilation to minimize the risk of alveolar rupture and its associated complications.