A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:

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Question 1 of 5

A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:

Correct Answer: C

Rationale: The ethical principle most relevant in this situation is autonomy. Autonomy refers to a person's right to make decisions about their own care and treatment. In this case, the client is expressing her wish to avoid surgery and believes her condition will improve on its own. It is important for the nurse to respect the client's autonomy and involve her in the decision-making process regarding her treatment. The nurse should provide information, support, and guidance to help the client make an informed decision that aligns with her values and preferences. While the nurse can provide education and encourage the client to consider the physician's recommendation, ultimately the decision should respect the client's autonomy.

Question 2 of 5

A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse administer?

Correct Answer: A

Rationale: Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, work by inhibiting the conversion of angiotensin I to angiotensin II. This leads to vasodilation, reduced aldosterone secretion, and ultimately decreases blood pressure. ACE inhibitors are commonly used in the management of hypertension, heart failure, and post-myocardial infarction. In this case, the nurse should administer captopril as it is an ACE inhibitor, while the other options (B. Furosemide, C. Spironolactone, D. Chlorothiazide) are not ACE inhibitors and have different mechanisms of action.

Question 3 of 5

The parent of a 3-year-old with suspected Wilms tumor says, 'How could I have missed a lump this big?' Which is the best response?

Correct Answer: D

Rationale: Wilms tumor can grow very quickly, so a lump that was not evident previously may become noticeable in a short period.

Question 4 of 5

A one month old infant is admitted for confirmation of the diagnosis of ventricular septal defect. During the initial admission assessment, the nurse would expect to find:

Correct Answer: D

Rationale: A ventricular septal defect (VSD) is a congenital heart defect where there is an abnormal opening between the two ventricles of the heart. One of the hallmark signs of VSD is the presence of a murmur, specifically a holosystolic murmur, which is typically heard best at the left sternal border due to the turbulent blood flow through the defect. This murmur is a key finding during the initial assessment of a patient with a suspected VSD. Other common symptoms of VSD include poor feeding, failure to thrive, tachypnea, and frequent respiratory infections.

Question 5 of 5

When testing visual fields, the nurse is assessing which of the following parts of vision?

Correct Answer: A

Rationale: When testing visual fields, the nurse is assessing the peripheral vision. Peripheral vision refers to the outer area of the visual field, away from the center of gaze. It allows individuals to detect objects, movement, and stimuli in their surroundings without needing to focus directly on them. Testing peripheral vision is important for detecting potential visual field deficits that can impede daily activities and safety, such as driving or navigating crowded spaces. By assessing the peripheral vision, healthcare professionals can identify any limitations or abnormalities that may require further evaluation or intervention.

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