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Questions 158

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Question 1 of 5

Which of the following nursing care goals has the highest priority for a child with epiglottitis?

Correct Answer: A

Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.

Question 2 of 5

A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

Correct Answer: B

Rationale: Swallowing assists with insertion of tube and closes off airway.

Question 3 of 5

The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:

Correct Answer: A

Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.

Question 4 of 5

A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:

Correct Answer: C

Rationale: A conversion reaction is a physical expression of an emotional conflict with no organic basis, such as paralysis in this case.

Question 5 of 5

Which of the following nursing care goals has the highest priority for a child with epiglottitis?

Correct Answer: A

Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.

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