Nokea
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery.
Incorrect choices:
B: Hiccups - Hiccups are not a common side effect of Ketamine administration.
C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions.
D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids.
Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.
You may also like to solve these questions
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
- A. Decreased oral intake and decreased oxygen saturation when ambulating NursingStoreRN Decreased oxygen saturation when ambulating and reports of shortness of breath
- B. when getting out of bed
- C. Reports of shortness of breath when getting out of bed and a productive cough
- D. Productive cough and decreased oral intake
Correct Answer: B
Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity.
Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living.
Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance.
Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Squeeze the nipple to check for drainage
- C. Check the area after the next menstrual period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.
Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above Charles is a 76 year old retired professional golfer. He has recently been diagnosed as having Parkinson’s disease.
Correct Answer: D
Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D. Asking the patient about usual sleep patterns and the onset of having difficulty resting is the best action for the nurse to take. This allows the nurse to gather more information and assess if there is a possible correlation between the leg cast and the restless sleep. It is important to consider all aspects of the patient's condition and not dismiss any symptoms.
Choice A is incorrect because telling the patient to just focus on the leg and cast disregards the patient's concerns about restless sleep.
Choice B is incorrect as simply documenting the information without further assessment does not address the patient's issue.
Choice C is incorrect as postponing a thorough assessment to the next shift may delay necessary intervention for the patient's sleep problem.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.