A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client’s platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: The correct answer is B: 20,000/ul. A platelet count below 20,000/ul puts the client at the highest risk for cerebral hemorrhage due to severe thrombocytopenia. Platelets are essential for blood clotting, and a low count increases the risk of spontaneous bleeding, especially in critical organs like the brain. Choices A, C, and D have platelet counts that are higher than the critical level of 20,000/ul, so they do not pose as high a risk for cerebral hemorrhage. Option D, 500/ul, is extremely low and would likely lead to severe bleeding, but the critical threshold for cerebral hemorrhage is considered to be around 20,000/ul.
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The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.
A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Rationale:
1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia.
2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling.
3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance.
4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage.
5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications.
Summary:
B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ.
C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation.
D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
- A. adenohypohysis.
- B. alpha cells of the pancreas.
- C. beta cells of the pancreas.
- D. parafollicular cells of the thyroid.
Correct Answer: C
Rationale: Rationale:
1. Insulin is a hormone produced by beta cells of the pancreas.
2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels.
3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells.
4. Adenohypophysis secretes other hormones, not insulin.
5. Alpha cells of the pancreas secrete glucagon, not insulin.
6. Parafollicular cells of the thyroid secrete calcitonin, not insulin.
Summary:
Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, “Why is my urine in the bag clotting like blood?” The nurse’s best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: The correct answer is A: after the surgery, bleeding is normal. This is because after a TURP procedure, it is common for some bleeding to occur, leading to blood clots in the urine bag. The surgical site undergoes trauma, causing bleeding as a part of the healing process.
Choice B is incorrect because while irrigation may be done post-surgery, blood clots in the urine bag are expected due to the surgery itself, not just irrigation. Choice C is incorrect as it is normal for some bleeding to occur after TURP, and immediate physician intervention is not necessary unless excessive bleeding is observed. Choice D is incorrect as tugging on the catheter may cause bleeding, but in this case, the presence of blood clots is likely due to the surgery itself, not catheter irritation.