A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a
strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes.
Which of the following nursing measures is most appropriate to meet the expected outcome of
positive body image?
C
Explanation:
Teaching the client and family about progression of the disease includes explaining when symptoms
can
be expected to improve and resolve. Knowledge of the course of the disease can help them
understand that no
permanent disruption in physical appearance will occur that could negatively affect body image.
Clients with
Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary
artery lesions
and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to
body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the
disease.Health
Promotion and Maintenance
Which of the following is most likely to impact the body image of an infant newly diagnosed with
Hemophilia?
D
Explanation:
Altered Family Processes is a potential nursing diagnosis for the family and client with a new
diagnosis of
Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an
immediate
impact on the infant’s development of trust and how others relate to them because of their
diagnosis. The longterm
effects of hemophilia can include problems related to immobility. Altered growth and development
could not
have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is
characteristic
of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed
hemophiliac.Health
Promotion and Maintenance
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a
medicine woman be present in the examination room. Which of the following is an appropriate
response by the nurse?
A
Explanation:
This statement reflects cultural awareness and acceptance that receiving support from a medicine
woman is
important to the client. The other statements are culturally insensitive and unprofessional.Reduction
of Risk
Potential
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
C
Explanation:
Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is
indicated.Reduction of Risk Potential
Which fetal heart monitor pattern can indicate cord compression?
A
Explanation:
Variable decelerations can be related to cord compression. The other patterns are not.Reduction of
Risk
Potential
Which of the following conditions is mammography used to detect?
B
Explanation:
Mammography is used to detect tumors or cysts in the breasts, not the other conditions.Reduction of
Risk
Potential
Why might breast implants interfere with mammography?
D
Explanation:
Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast
implants
interfere with mammography.Reduction of Risk Potential
Which of the following instructions should the nurse give a client who will be undergoing
mammography?
B
Explanation:
Underarm deodorant should not be used because it might cause confusing shadows on the X-ray
film. There
are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself
home.Reduction of
Risk Potential
Which of the following diseases or conditions is least likely to be associated with increased potential
for bleeding?
C
Explanation:
Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result
from
inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic
factor
normally produced by gastric mucosal cells and certain disorders of the small intestine that impair
absorption.
The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as
the need for
folic acid, rest, diet, and support.Physiological Adaptation
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to
the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU,
continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a
positive response to Heparin therapy?
B
Explanation:
Effective Heparin therapy should stop the process of intravascular coagulation and result in increased
availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of
fibrinogen to
fibrin. Bleeding should cease due to the increased availability of platelets and coagulation
factors.Physiological
Adaptation