Nokea
You would not find which of the following assessments in a patient with severe anemia?
- A. Pallor
- B. Fatigue
- C. Cold sensitivity
- D. Dyspnea only on exertion
Correct Answer: C
Rationale: Severe anemia is associated with a reduced number of red blood cells, leading to decreased oxygen delivery to the body's tissues. Therefore, symptoms commonly seen in patients with severe anemia include pallor (pale skin), fatigue (due to decreased energy levels), and dyspnea (shortness of breath) especially on exertion (due to the heart working harder to compensate for the reduced oxygen-carrying capacity of the blood). Cold sensitivity is not a typical symptom of anemia and is not directly related to the reduced oxygen-carrying capacity of the blood.
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Childhood primary brain stem tumors are a heterogeneous group of tumors; the outcome usually depends on the tumor location. Which tumor, depending on the site of tumor, carries the worst prognosis?
- A. focal dorsally exophytic
- B. cervicomedullary diffuse intrinsic
- C. none of the above
- D. diffuse intrinsic
Correct Answer: D
Rationale: Diffuse intrinsic pontine gliomas (DIPG) have the worst prognosis among brainstem tumors.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: Steroids should not be abruptly stopped, especially in patients on long-term therapy, because higher steroid levels are needed during stress. Abruptly stopping steroids can lead to adrenal insufficiency and a life-threatening condition called adrenal crisis. Patients undergoing surgery or experiencing significant stress require higher doses of steroids to prevent adrenal crisis. It is important for healthcare providers to monitor and adjust steroid doses accordingly during stressful situations such as surgery.
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.
When educating parents regarding known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?
- A. Scabies
- B. Impetigo
- C. Herpes simplex
- D. Varicella
Correct Answer: B
Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children. Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.
You are meeting with parents of a 10-year-old child who recently develops acute lymphoblastic leukemia (ALL). Which of the following is LEAST likely to increase the risk of CNS relapse in children with ALL?
- A. first traumatic lumbar puncture (LP)
- B. T-cell leukemia
- C. cranial nerve involvement at the time of diagnosis
- D. presence of lymphoblast in the CSF at any time during treatment
Correct Answer: A
Rationale: A first traumatic lumbar puncture is less likely to increase the risk of CNS relapse compared to other factors like T-cell leukemia or cranial nerve involvement.