Nokea
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her gallbladder
- B. There are stones present in her kidneys
- C. There are stones present in her common bile duct
- D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
Correct Answer: C
Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
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Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) involves logical, coherent thinking about concrete events, not abstract concepts. Perspective-taking improves but is secondary to logical thought.
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction. What tests should the nurse anticipate?
- A. Reticulocyte count, creatinine phosphokinase (CPK)
- B. Aspartate transaminase, alanine transaminase
- C. Sedimentation rate, WBC count
- D. Lactic dehydrogenase, CPK
Correct Answer: D
Rationale: Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The physician verifies the exact time of birth.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
Correct Answer: D
Rationale: Tagging the mother and infant with identical bands ensures proper identification, preventing mix-ups and ensuring safety.
The nurse is caring for a client with a history of systemic lupus erythematosus. The nurse should expect the client to have:
- A. Joint pain
- B. Tremors
- C. Visual loss
- D. Abdominal pain
Correct Answer: A
Rationale: Systemic lupus erythematosus causes autoimmune inflammation, commonly leading to joint pain and arthritis-like symptoms.
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
- A. Avoid potassium-rich foods
- B. Increase sodium intake
- C. Take the medication at bedtime
- D. Limit fluid intake
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.