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A nurse is providing discharge teaching to a client who had a bilateral architectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. After a bilateral adrenalectomy, the client will have decreased cortisol production, leading to adrenal insufficiency. This can result in hypoglycemia due to decreased glucose regulation. Increased libido (B) and increased muscle mass (D) are not typical symptoms following this procedure. Hot flashes (C) are more commonly associated with menopause.
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A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chronic level
- B. Creatinine kinase
- C. Uric acid
- D. Immac factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in the production or decrease in the excretion of uric acid, leading to elevated levels in the blood. This results in the formation of urate crystals in the joints, causing inflammation and pain. Choices A, B, and D are unrelated to acute gout. A chronic level (Choice A) does not indicate an acute condition. Creatinine kinase (Choice B) is an enzyme related to muscle damage, not specific to gout. Immac factor (Choice D) is not a relevant marker for acute gout. Therefore, the correct answer is C as it directly correlates with the pathophysiology of acute gout.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 38.3°C (100.9°F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.