Nokea
A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Darken the client's room and provide a quiet environment.
- B. Provide a low-sodium, bland diet.
- C. Administer an opioid to relieve headache.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: A dark, quiet environment reduces stimuli that can exacerbate vertigo in Ménière's disease.
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A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
- A. Hematocrit 65% (0.65)
- B. Albumin 4.0 g/dL (40 g/L)
- C. Sodium 140 mEq/L (140 mmol/L)
- D. White blood cell (WBC) count 6000 mm^3 (6 x 10^9/L)
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
The nurse is caring for a 25-year-old client who will undergo bilateral orchiectomy for testicular cancer. Considering the nature of the illness, the nurse should make it a priority to explore which potential psychological concern with this client?
- A. Postoperative pain
- B. Postoperative swelling
- C. Loss of reproductive ability
- D. Length of recuperative period
Correct Answer: C
Rationale: Although the client will need factual information about the postoperative period and recuperation, the nurse should place priority on addressing loss of reproductive ability as a psychological concern. The radical effects of this surgery in the reproductive area make it likely that the client may have some difficulty in adjustment to this consequence of surgery.
A client with a diagnosis of Parkinson's disease is prescribed pramipexole (Mirapex). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Pramipexole, a dopamine agonist, commonly causes drowsiness, which the nurse should monitor in Parkinson's clients.
A couple has completed testing and is a candidate for in vitro fertilization. The nurse is reviewing the procedure with them and realizes that further instruction is needed when the woman states:
- A. One of the greatest risks is multiple pregnancies.'
- B. I will need to redefine how I view my job if I do become pregnant.'
- C. The fertilization procedure can be done anytime during my cycle.'
- D. We can use our own eggs and sperm or someone else's.'
Correct Answer: C
Rationale: IVF requires precise timing with the menstrual cycle, so the statement about performing it anytime indicates a need for further instruction.
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.