When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?

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Question 1 of 5

When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?

Correct Answer: A

Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.

Question 2 of 5

A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?

Correct Answer: C

Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.

Question 3 of 5

When caring for a client with diabetes insipidus, the nurse expects to administer:

Correct Answer: A

Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to conserve water due to reduced secretion of antidiuretic hormone (ADH), also known as vasopressin. Therefore, the treatment for diabetes insipidus typically involves administering synthetic vasopressin, such as desmopressin (DDAVP) or vasopressin (Pitressin Synthetic), to replace the deficient hormone and help the kidneys reabsorb more water. Vasopressin helps regulate water balance in the body by increasing water reabsorption in the kidneys, reducing urine output, and preventing dehydration. Therefore, the nurse would expect to administer vasopressin to a client with diabetes insipidus to help manage the condition effectively.

Question 4 of 5

Mrs. Adams is scheduled for an intravemous pyelogram (IVP). Nurse Aura wpould be most concerned if the patient makes which of the following comments or statements?

Correct Answer: A

Rationale: Nurse Aura would be most concerned about the patient's statement regarding taking Senokot daily because laxatives can affect kidney function and urine production, which are important considerations during an intravenous pyelogram (IVP). Laxatives can lead to dehydration and electrolyte imbalances, which may affect the results and safety of the IVP procedure. It is crucial for the patient to disclose any medications or substances they are taking that could impact kidney function or urine production prior to undergoing the IVP. The other statements are not directly related to the IVP procedure or potential complications.

Question 5 of 5

Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:

Correct Answer: C

Rationale: The symptoms described in the scenario - dyspnea, tachypnea, crackles in lung fields, and coughing up thick, white sputum - are indicative of fat embolism syndrome (FES), which occurs as a complication of long bone fractures like the femur fracture in this case. FES is characterized by the release of fat droplets into the bloodstream, which can then travel to the lungs and cause respiratory distress. The onset of symptoms typically occurs within 24-72 hours after the initial injury, making it a likely cause for Ms. Slovenski's condition. This is a medical emergency that requires prompt recognition and intervention to prevent further complications. The other options (A, B, and D) do not align with the clinical picture presented in the scenario and are less likely causes of her current symptoms.

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