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: The correct answer is C: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.
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Why is heart biopsy performed throughout a clients lifetime after heart transplantation?
- A. To detect rejection
- B. To check the heart functionality
- C. To check rate of the heartbeat
- D. To check for heart tumor CARING FOR CLIENTS WITH HYPERTENSION
Correct Answer: A
Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications.
Other choices are incorrect:
B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy.
C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy.
D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, “I don’t understand how this medication works. Will it stop the infection?” What is the nurse’s best response?
- A. The medication helps to slow the disease process, but it won’t cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don’t you know? There aren’t medication to stop or cure HIV
- D. No. it won’t stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV.
Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.
Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.