A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
- A. Make sure he drinks 8 glasses of water a day.
- B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
- C. Look for signs of hyperchloremia
- D. Observe for neurologic changes
Correct Answer: B
Rationale: The 78-year-old male in this scenario is at risk for electrolyte imbalances due to prolonged exposure to high temperatures while taking thiazide diuretics, commonly prescribed for hypertension. The low potassium level (K 3.7 mEq/L) and low sodium level (Na 129 mEq/L) in his lab results are indicative of potential electrolyte disturbances, especially considering his age and medication. These electrolyte imbalances can lead to symptoms like fatigue, muscle weakness, restlessness, and flushed skin, which are signs of hyponatremia and hypokalemia.
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Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. " Right after the operation, I will wear the pneumatic compression device while sitting on the chair."
- B. "I will not eat anything after 12 pm the night befire my operation, but I sure can drink."
- C. "The skin preparation site is longer and wider than the actual incision site."
- D. "I will need to sign the consent from after I get to the operating table."
Correct Answer: B
Rationale: Option B, "I will not eat anything after 12 pm the night before my operation, but I sure can drink," indicates that the client understands and is knowledgeable about the pre-operative fasting guidelines. It is crucial for patients to have an empty stomach before surgery to prevent complications related to anesthesia, such as aspiration pneumonia. This statement shows that Mr. Sy is well-informed and compliant with this important pre-operative instruction. Options A, C, and D do not directly demonstrate specific knowledge regarding the surgery preparations.
A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
- A. Buttocks
- B. Tip of nose and sclera
- C. Sclera, conjunctiva, and oral mucosa
- D. Palms of hands and soles of feet
Correct Answer: C
Rationale: The best place to assess for jaundice in a dark-skinned newborn is in the sclera, conjunctiva, and oral mucosa. Jaundice, which is caused by elevated levels of bilirubin in the blood, is more easily seen in these areas compared to the skin. While jaundice is commonly assessed on the skin in light-skinned individuals, it may not be as readily apparent in dark-skinned newborns. Therefore, examining the sclera, conjunctiva, and oral mucosa for a yellowish discoloration provides a more reliable indication of jaundice in dark-skinned infants. This approach ensures that healthcare providers can accurately detect and monitor jaundice in newborns of all skin tones.
The spouse of a client with gastric cancer expresses concern that the couple's children may develop this type of cancer when they're older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
- A. Type A
- B. Type AB
- C. Type B
- D. Type O
Correct Answer: A
Rationale: Among the different blood types, individuals with blood type A have been found to have a slightly higher risk of developing gastric cancer. Research has shown that individuals with blood type A are associated with a 10% increased risk of gastric cancer compared to other blood types. This information is important to consider when discussing potential risk factors for gastric cancer with clients and their families.
The clinical manifestations of Parkinson's disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
- A. Acetylcholine
- B. Serotonin
- C. Dopamine
- D. Phenylalanine
Correct Answer: C
Rationale: The clinical manifestations of Parkinson's disease, including bradykinesia, rigidity, and tremors, are directly related to a decreased level of dopamine in the brain. Dopamine is a neurotransmitter that plays a crucial role in regulating movement and coordination. A decrease in dopamine levels results in the characteristic motor symptoms observed in Parkinson's disease. The treatment for Parkinson's disease often involves medications that help increase dopamine levels in the brain, such as levodopa, to alleviate these symptoms.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: B
Rationale: - **Encourage a liberal fluid intake (B):** It is essential to maintain hydration after a lumbar puncture to help prevent or alleviate a headache, which may occur due to a decrease in cerebrospinal fluid (CSF) pressure. Adequate hydration can help reduce the chances of a post-lumbar puncture headache.