Nokea
A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:
- A. Inability to chew
- B. Inability to look laterally
- C. Inability to swallow
- D. Loss of scalp sensation
Correct Answer: B
Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.
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Additional assessment on Antoinette include
dehydration and menorrhagia.
- A. buffalo hump and hypertension.
- B. pitting edema and frequent colds.
- C. migraine headache and dymennorhea.
Correct Answer: B
Rationale: Cushing's syndrome results from excess adrenocortical activity. Signs include slow wound healing, buffalo hump, hirsutism, weight gain, hypertension, acne, moon face, thin arms and legs, and behavioral changes.
A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
- A. can no longer produce any insulin.
- B. produce minimal amounts of insulin.
- C. are unable to administer their injections.
- D. have a sustained decreased blood glucose.
Correct Answer: B
Rationale: Tolbutamide, an oral hypoglycemic, is effective for type 2 diabetes patients who produce minimal insulin, stimulating insulin release. Type 1 diabetics (A) produce no insulin, injection inability (C) is irrelevant, and low blood glucose (D) is not an indication for tolbutamide.
The client is receiving chemotherapy for cancer. Which statement, if made by the client, would indicate that she has accepted the diagnosis and treatment?
- A. I hate getting that treatment.'
- B. The doctor isn't sure if I really have cancer.'
- C. I have a collection of pretty scarves that I am wearing a lot now.'
- D. I don't go anywhere except for my treatments because I look so weird.'
Correct Answer: C
Rationale: Wearing scarves suggests acceptance of chemotherapy-induced hair loss, indicating adaptation to treatment and diagnosis.
Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).
Priority nursing care on the patient with PIH include:
- A. Urinary protein, 2 grams/24hous.
- B. HR 110 bpm.
- C. Urine output 335 ml/24 hours.
- D. Patellar reflex positive.
Correct Answer: C
Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.