Nokea
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT.
Rationale:
A) RBC count: AZT can cause anemia, not specifically affecting the RBC count.
B) Serum calcium: AZT does not typically affect calcium levels.
C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.
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A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.
A male client is prescribed medications that depress thrombocytes. The nurse should monitor for which of the ff signs and symptoms in the client?
- A. Sore throat and swollen glands
- B. Pernicious anemia with weakness
- C. Bleeding gums and dark tarry tools
- D. Thickening of blood and bruising
Correct Answer: C
Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function.
A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression.
B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression.
D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.
The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?
- A. Type I
- B. Type III
- C. Type II
- D. Type IV
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. In Type I hypersensitivity, anaphylactic reactions involve immediate IgE-mediated responses to allergens, leading to histamine release and potentially life-threatening symptoms. This type of reaction is characterized by rapid onset and systemic involvement. Choices B, C, and D are incorrect because Type III reactions involve immune complex deposition leading to inflammation (B), Type II reactions involve cytotoxic antibodies targeting cells (C), and Type IV reactions involve delayed cell-mediated responses (D).
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: A
Rationale: The correct answer is A: Bladder control. This is the major early problem for Mr. Gabatan because urinary retention is a common complication post-surgery, especially for older males like him. Bladder control is essential for preventing urinary tract infections and maintaining overall health. Quadriceps setting (B) and client education (C) are important but not as critical early on. Use of aids for ambulation (D) is important but not the major early problem compared to bladder control in this case.
A 68-year old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
- A. Diabetes mellitus
- B. Hypoparathyroidism
- C. Diabetes insipidus
- D. Hyperparathyroidism
Correct Answer: D
Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.