Nokea
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
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A client undergoing chemotherapy has a white blood cell count of 2300/mm³; hemoglobin of 9.8 g/dL; platelet count of 80,000/mm³ and potassium of 3.8. Which of the following should take priority?
- A. Blood pressure 136/88.
- B. Emesis of 90 mL.
- C. Temperature 101°F (38.3°C).
- D. Urine output 40 mL/hour.
Correct Answer: C
Rationale: A fever of 101°F in a neutropenic client (WBC 2300/mm³) indicates a high risk of infection, which is a priority due to potential for rapid deterioration.
The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply.
- A. Presbyopia
- B. Tinnitus
- C. Vertigo
- D. Dyskinesia
- E. Hearing loss
Correct Answer: B,C,E
Rationale: Meniere's disease is characterized by tinnitus (ringing in the ears), vertigo (spinning sensation), and hearing loss due to inner ear dysfunction. Presbyopia (age-related vision loss) and dyskinesia (abnormal movements) are not associated with Meniere's disease.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
After a bilateral adrenalectomy for Cushing's disease, the client will receive periodic testosterone injections. The expected outcome of these injections is:
- A. Balanced reproductive cycle.
- B. Maintained fluid and electrolyte balance.
- C. Stimulated protein metabolism.
- D. Stabilized mood swings.
Correct Answer: C
Rationale: Testosterone injections post-adrenalectomy stimulate protein metabolism, supporting tissue repair and muscle maintenance.
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:
- A. The prosthesis may cause a problem with the electrosurgical unit used to control bleeding.
- B. The client should not have her hip externally rotated when she is positioned for the procedure.
- C. The perioperative nurse can inform the rest of the team about the total hip replacement.
- D. There is not enough time to notify the surgeon and note this finding on the history and physical information before the procedure.
Correct Answer: A
Rationale: A hip prosthesis can conduct electricity from an electrosurgical unit, risking burns or complications. Communicating this ensures precautions are taken during surgery.