Nokea
A client with breast cancer presents with back pain, weakness, and difficulty urinating. The nurse suspects spinal cord compression. The priority nursing action is to:
- A. Administer analgesics immediately.
- B. Notify the physician for urgent evaluation.
- C. Encourage bed rest in a supine position.
- D. Perform a bladder scan.
Correct Answer: B
Rationale: Spinal cord compression is a medical emergency requiring urgent physician evaluation for imaging and interventions like corticosteroids or surgery to prevent permanent neurologic damage.
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When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf
- B. Burning pain in the left calf
- C. Numbness and tingling in the left leg
- D. Coldness of the left foot and ankle
Correct Answer: D
Rationale: Complete arterial obstruction causes severe ischemia, leading to coldness of the affected limb (foot and ankle) due to absent blood flow. Aching or burning pain and numbness/tingling suggest partial occlusion or neuropathy, not complete obstruction.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for:
- A. Footdrop.
- B. Knee swelling and pain.
- C. Tingling in the arm.
- D. Absence of the Achilles reflex.
Correct Answer: C
Rationale: Thoracoscopy positioning (lateral decubitus) can compress nerves in the arm, causing tingling due to brachial plexus injury. Footdrop or Achilles reflex issues are unrelated to this position.
A client reports that she has gained weight and that her face and body are 'rounder,' while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. When examining this client, the nurse would expect to find:
- A. Orthostatic hypotension.
- B. Muscle hypertrophy in the extremities.
- C. Bruised areas on the skin.
- D. Decreased body hair.
Correct Answer: C
Rationale: Cushing's disease causes thin, fragile skin due to excess cortisol, leading to easy bruising.
Which of the following signs and symptoms are common in male clients with prolactin-secreting tumors?
- A. Severe lethargy and fatigue.
- B. Erectile dysfunction and decreased libido.
- C. Both of the above
- D. None of the above
Correct Answer: B
Rationale: Prolactin-secreting tumors in males often cause erectile dysfunction and decreased libido due to suppression of testosterone.