Nokea
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add?
- A. Related to bone demineralization resulting in pathologic fractures
- B. Related to exhaustion secondary to an accelerated metabolic rate
- C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
- D. Related to tetany secondary to a decreased serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Related to bone demineralization resulting in pathologic fractures. In chronic hyperparathyroidism, there is excessive release of parathyroid hormone, leading to increased bone resorption and calcium release from bones, causing bone demineralization and weakening. This puts the client at risk for pathologic fractures. Choice B is incorrect because exhaustion is not a direct consequence of chronic hyperparathyroidism. Choice C is incorrect as edema and dry skin are not typical manifestations of hyperparathyroidism. Choice D is incorrect because tetany is more commonly associated with hypocalcemia, which is not a typical finding in hyperparathyroidism.
You may also like to solve these questions
Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.
Through which of the ff body fluids has transmission of HIV been established? Choose all that apply
- A. Saliva
- B. Sweat
- C. Tears f. Breastmilk
- D. Blood g. Urine
Correct Answer: C
Rationale: The correct answer is C: Tears and F: Breastmilk. HIV transmission has been established through breastmilk due to the presence of the virus in the milk. Tears can also transmit HIV if they contain blood from an HIV-positive individual. Saliva, sweat, and urine do not typically contain enough HIV to transmit the virus. Blood is a well-known mode of HIV transmission due to the high viral load present in blood. Therefore, choices A, B, D, and G are incorrect as they do not have sufficient levels of the virus to transmit HIV.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms.
Incorrect choices:
A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine.
B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
- A. notify the physician and anticipate emergency surgery
- B. assess the apical and radial pulses for any irregularity and notify the physician
- C. elevate the foot of the bed and apply warm compress
- D. obtain a Doppler and recheck the pedal pulses
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action.
Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?
- A. Sharp pain in the knee
- B. Small bloody drainage on dressing
- C. Temperature of 102 degrees F
- D. Pulse rate of 90 beats per minute
Correct Answer: A
Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain.
B: Small bloody drainage is an objective cue that can be observed and measured by the nurse.
C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer.
D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter.
In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.