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A 48-year-old woman is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor the patient's
- A. complete blood count (CBC).
- B. temperature.
- C. specific gravity of urine.
- D. intracranial pressure.
Correct Answer: C
Rationale: Transsphenoidal hypophysectomy risks diabetes insipidus from ADH disruption, detected by low urine specific gravity. Options A, B, and D are less specific.
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A 68-year-old man is diagnosed with myasthenia gravis. The nurse instructs the client about his disease. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching?
- A. I should not drink alcoholic beverages.
- B. I should not go places that are crowded.
- C. I should try to stay calm.
- D. I should use my hot tub daily.
Correct Answer: D
Rationale: Hot tubs cause heat exposure, which can exacerbate myasthenia gravis symptoms, indicating a need for further teaching. Options A, B, and C are correct: alcohol worsens symptoms, crowds increase infection risk, and stress can trigger exacerbations.
An adult is admitted with pernicious anemia. Which factor in the client's history is most likely related to the development of pernicious anemia?
- A. The client had an upper gastrointestinal (GI) bleed a year ago.
- B. The client had chemotherapy three months ago.
- C. The client had a gastrectomy six months ago.
- D. The client's mother had iron deficiency anemia
Correct Answer: C
Rationale: Gastrectomy removes the stomach's intrinsic factor-producing cells, leading to vitamin B12 malabsorption, a primary cause of pernicious anemia.
A client is admitted with suspected fracture of the left hip. The most consistent finding in the client with the hip fracture is:
- A. Pain in the hip and affected leg
- B. Absence of pedal pulses
- C. Disalignment of the leg
- D. Diminished sensation
Correct Answer: C
Rationale: Disalignment of the leg , such as shortening or external rotation, is the most consistent sign of a hip fracture. Pain is common but less specific. Pulses and sensation are typically intact.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.