What orders would likely be included fro a client diagnosed with multiple myeloma?
- A. Bed rest
- B. Fluid restriction
- C. Corticosteroid therapy
- D. Calcium replacement therapy
Correct Answer: C
Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client.
A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization.
B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance.
D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.
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Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.
The initial neurological symptom of Guilain-Barre Syndrome is:
- A. Absent tendon reflex
- B. Paresthesia of the legs
- C. Dysrhythmias
- D. Transient hypertension Toni a 32 year old mother of two has had multiple sclerosis for 5 years. She is currently enrolled in a school of nursing. Her husband is supportive and helps with care of their preschool sons. Toni has been admitted to the clinical area for diagnostic studies related to symptoms of visual disturbances.
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs.
Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS.
Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom.
Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation.
In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.
Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client’s color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.