Physiological Adaptation
While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? -renal disorders -Potter's syndrome -ambiguous genitalia -Turner's syndrome
A: ambiguous genitalia Rationale: An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present.Renal disorders are associated with absence of a kidney and oliguria.Potter's syndrome is a fatal condition involving renal agenesis and facial deformities.Turner's syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.
A client has urge incontinence. When obtaining the health history, the nurse should ask the client about which factors that could precipitate incontinence? -inability to empty the bladder -loss of urine when coughing -involuntary urination -frequent dribbling of urine
A: involuntary urination Rationale: A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? -restricting fluids to 800 ml/day -administering vasopressin as ordered -elevating the head of the client's bed to 90 degrees -restricting sodium intake to 1 gm/day
A: restricting fluids to 800 ml/day Rationale: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which finding should lead the nurse to determine a client has a risk for infection? -dialysate leakage -granulation tissue -increased time for drainage -tissue swelling
A: tissue swelling Rationale: Tissue swelling, pain, redness, and exudate indicate infection. Dialysate leakage is associated with improper catheter function, incomplete healing at the insertion site, or excessive instillation of dialysate. Granulation tissue indicates healing around the exit site, not infection. Increased time for drainage may indicate that the tube is kinked, suggesting an obstruction.
A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma: -frequently resolves without treatment. -is typically treated with sustained bed rest. -is a medical emergency that can rapidly lead to blindness. -is most commonly treated with steroid therapy.
A: is a medical emergency that can rapidly lead to blindness. Rationale: Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.
The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? -pulse rate increased by 20 bpm immediately after the activity -respiratory rate decreased by 5 breaths/minute -diastolic blood pressure increased by 7 mm Hg -pulse rate within 6 bpm of resting pulse after 3 minutes of rest
A: respiratory rate decreased by 5 breaths/minute Rationale: A client has urge incontinence. When obtaining the health history, the nurse should ask the client about which factors that could precipitate incontinence? inability to empty the bladder loss of urine when coughing involuntary urination frequent dribbling of urine
The parent of a young child diagnosed with low-dose lead exposure asks about long-term effects. Which conditions should the nurse mention as possible long-term effects to this parent? Select all that apply. -seizures -depression -hyperactivity -aggression -impulsiveness
A: -hyperactivity -aggression -impulsiveness Rationale: The neurologic system can be affected and cause long-term consequences in a young child exposed to lead. Common behavioral effects include hyperactivity, impulsivity, and aggression. Seizures may occur in a child with high-dose lead exposure. Depression is not usually associated with lead exposure.
The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment? -Keep the client warm. -Maintain room temperature at 78°F (25.6°C). -Keep the client uncovered. -Match the room temperature to the client's body temperature.
A: Keep the client warm. Rationale: Vasodilation or vasoconstriction will affect the assessment findings in a client with PVD, so the nurse would keep the client warm. The nurse would keep the client covered and expose only the portion of the client's body that the nurse is assessing. The nurse would also keep the client warm by maintaining the room temperature between 68°F and 74°F (20° and 23.3°C). Extreme temperatures have a negative effect on clients with PVD. Keeping the client uncovered would cause the client to become chilled. Matching the room temperature to the client's body temperature is inappropriate.
A client is diagnosed with genital herpes (herpes simplex virus type 2, or HSV-2). What information should the nurse give to the client about managing this health problem? -Using occlusive ointments may decrease the pain from the lesions. -Reducing stressful life events may decrease the incidence of herpetic outbreaks. -There are no effective drug therapies to manage herpes symptoms. -Herpes is transmitted to partners only when lesions are weeping.
A: Reducing stressful life events may decrease the incidence of herpetic outbreaks. Rationale: Managing stressful life events can decrease the incidence of outbreaks of HSV-2. Occlusive ointments should not be applied. Antiviral therapies will not cure herpes, but they can manage symptoms and decrease the incidence of outbreaks. Clients with HSV-2 should use condoms to prevent HSV transmission. Cells can be shed at other times, not only when the vesicles are weeping.
A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8° F (38.2 ° C) rectally. The nurse is having difficulty calming the child. What should the nurse do next? -Administer acetaminophen. -Notify the health care provider (HCP) immediately. -Allow the toddler to continue to cry. -Offer clear fluids every few minutes.
A: Notify the health care provider (HCP) immediately. Rationale: The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/minute. The child's respiratory rate is 48 breaths/minute. Therefore the HCP needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101° F (38.6° C) or higher. Letting the toddler cry is inappropriate with croup because crying increases respiratory distress. Offering fluids every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possibly increasing the risk of aspiration.
A nurse takes all of these actions when caring for a client with hypothyroidism. Which intervention is the priority? -administering liothyronine -administering acetaminophen for headache -increasing room temperature and providing blankets -assessing for periorbital edema
A: administering liothyronine Rationale: Liothyronine is triiodothyronine (T3) and is often administered to a client with hypothyroidism. This is the priority to increase thyroid hormone levels. The other interventions would be lower-level priorities.
