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A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.
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A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with the client? (Select all that apply.)
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure should include: A) Culturally diverse materials to ensure relevance and understanding across different backgrounds; B) Accurate and current information to provide the client with up-to-date knowledge for managing their condition effectively; C) Materials written at an eighth-grade level to ensure clarity and ease of comprehension; D) Materials in the client's spoken language to facilitate understanding and communication. These tools are essential for effective patient education in heart failure management. Other choices are incorrect as they may not address the client's specific needs or may hinder their understanding of the information.
A nurse is reinforcing dietary teaching with a client who tells the nurse she would like to reduce her solid fat intake and increase oil intake in her diet. Which of the following instructions should the nurse include in the teaching?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier option than butter as it is a plant-based oil that is lower in solid fats and higher in unsaturated fats. Solid fats like butter contain more saturated fats which can raise cholesterol levels. By substituting safflower oil for butter, the client can reduce solid fat intake and increase oil intake in a heart-healthy way.
Incorrect answers:
A: Replace tub margarine with stick margarine - Both tub and stick margarine are solid fats and should be limited in the diet to reduce solid fat intake.
C: Consume 2% or whole milk - Whole milk contains more solid fats compared to low-fat or skim milk, so this would not be a good choice to reduce solid fat intake.
D: Choose ground beef that is at least 80% lean meat - While lean meats are a good choice to reduce solid fat intake, ground beef still contains saturated fats.
A nurse is caring for a client who has hemophilia and has developed hemarthrosis of the left knee. Which of the following actions should the nurse take?
- A. Administer low-dose aspirin.
- B. Apply heat to the knee.
- C. Administer analgesics IM.
- D. Elevate the knee.
Correct Answer: D
Rationale: The correct answer is D: Elevate the knee. Elevating the knee helps reduce swelling and promote venous return, which can help alleviate pain and prevent further bleeding in hemarthrosis. Administering low-dose aspirin (A) is contraindicated in hemophilia as it can increase the risk of bleeding. Applying heat (B) can exacerbate bleeding by increasing blood flow to the area. Administering analgesics IM (C) may provide pain relief but does not address the underlying issue of bleeding.