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A client is brought to the emergency department after a motor vehicle accident in which she suffered a spinal cord injury at the level of C5. Which of the following assessments should be the priority?
- A. Monitoring urinary output
- B. Monitoring heart rate and rhythm
- C. Monitoring respiratory rate
- D. Monitoring the client's pain levels
Correct Answer: B
Rationale: The correct answer is monitoring heart rate and rhythm. With a C5 spinal cord injury, monitoring heart rate and rhythm is crucial as it can impact autonomic regulation. This level of injury can affect cardiac function due to the disruption of sympathetic nerve fibers. Monitoring urinary output may be important to assess for urinary retention, but it is not the priority in this scenario. While monitoring respiratory rate is essential in all patients, in this case, cardiovascular stability takes precedence. Pain management is important but is not the priority when assessing a client with a C5 spinal cord injury.
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Which clients are at highest risk for pneumonia?
- A. Those in their 20s and 30s and generally healthy
- B. Those who exercise regularly and are not exposed to pathogens
- C. Those who are hospitalized and immunocompromised
- D. Those who have adequate respiratory function
Correct Answer: C
Rationale: Clients who are hospitalized and immunocompromised are at the highest risk for pneumonia due to their weakened immune systems. Choice A is incorrect as young and healthy individuals typically have stronger immune systems. Choice B is incorrect because regular exercise can actually boost the immune system and reduce the risk of infections. Choice D is incorrect as having adequate respiratory function does not necessarily correlate with the risk of developing pneumonia.
What serious adverse effect should the nurse monitor for during testosterone therapy?
- A. Testosterone therapy increases the risk of cardiovascular events, so regular monitoring is essential.
- B. Testosterone therapy can cause liver dysfunction, so liver function tests should be monitored regularly.
- C. Testosterone therapy can lead to prostate cancer, so regular screenings are recommended.
- D. Testosterone therapy can lead to bone fractures, so bone density should be monitored.
Correct Answer: A
Rationale: The correct answer is A. Testosterone therapy is associated with an increased risk of cardiovascular events. Therefore, the nurse should monitor the patient for cardiovascular complications. While monitoring liver function tests (choice B) and bone density (choice D) may be important in some cases, the primary concern during testosterone therapy is the risk of cardiovascular events. Prostate cancer screenings (choice C) are not directly related to testosterone therapy's adverse effects.
A nurse is caring for a patient who is being treated with clomiphene citrate (Clomid) for infertility. What side effect should the nurse warn the patient about?
- A. Headaches and visual disturbances
- B. Nausea and vomiting
- C. Hot flashes and abdominal discomfort
- D. Fatigue and depression
Correct Answer: C
Rationale: The correct answer is C: 'Hot flashes and abdominal discomfort.' Clomiphene citrate, commonly known as Clomid, can lead to hot flashes and abdominal discomfort as side effects. It is important for the nurse to warn the patient about these potential effects. Choices A, B, and D are incorrect because headaches and visual disturbances, nausea and vomiting, as well as fatigue and depression are not commonly associated with clomiphene citrate use.
What is the best way to prevent transmission of infectious agents?
- A. Take antibiotics daily
- B. Call the practitioner for herbal supplements
- C. Wash hands
- D. Avoid public areas as much as possible
Correct Answer: C
Rationale: The correct answer is C: Wash hands. Washing hands is the most effective way to prevent the transmission of infectious agents. Antibiotics are not effective in preventing infections, and their overuse can lead to antibiotic resistance. Calling a practitioner for herbal supplements is not a primary method for preventing the transmission of infectious agents. Avoiding public areas entirely is impractical and not as effective as proper hand hygiene.
A 21-year-old male is being started on zidovudine (AZT) for the treatment of HIV/AIDS. Which of the following statements made by the patient indicates that he has understood the patient teaching?
- A. "AZT inactivates the virus and prevents recurrence of the disease."
- B. "AZT therapy may result in the development of AZT-resistant strains."
- C. "AZT slows the progression of the disease but does not cure it."
- D. "AZT prevents the occurrence of opportunistic infections."
Correct Answer: C
Rationale: The correct answer is C. When the patient states, "AZT slows the progression of the disease but does not cure it," it shows an understanding that zidovudine (AZT) does not provide a cure for HIV/AIDS but helps in slowing down the progression of the disease. Choice A is incorrect because AZT does not inactivate the virus or prevent recurrence. Choice B is incorrect as AZT resistance can develop with therapy. Choice D is incorrect because while AZT can help prevent opportunistic infections by boosting the immune system, its primary action is not the prevention of opportunistic infections.