A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. 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: C
Rationale: The correct answer is C: Hot flashes. After a bilateral orchiectomy (removal of both testicles), there is a sudden decrease in testosterone levels, leading to hormonal imbalances. This can result in hot flashes, which are commonly experienced by men undergoing androgen deprivation therapy. Hypoglycemia (A) is not typically associated with orchiectomy. Increased libido (B) and increased muscle mass (D) are actually expected to decrease due to the decrease in testosterone levels post-orchiectomy.
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A nurse is caring for a client who has heart failure. Which of the following findings indicate the client is at risk for developing complications?
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A, dysrhythmias. In heart failure, the heart's inability to pump effectively can lead to electrical disturbances causing dysrhythmias, which can be life-threatening. Dysrhythmias can result in decreased cardiac output, further exacerbating heart failure. Respiratory alkalosis (B) is not a direct complication of heart failure. Acute kidney injury (C) can occur due to decreased cardiac output, leading to decreased renal perfusion, but it is not a direct risk factor for complications in heart failure. Fluid volume deficit (D) is a common finding in heart failure due to fluid retention, but it is not a direct risk for complications like dysrhythmias.
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my digoxin if my pulse is less than 50 beats per minute.
- B. I will take this medication with fiber to prevent constipation.
- C. I will increase my dose if my vision becomes blurred.
- D. I will notify my provider if I experience muscle weakness.
Correct Answer: D
Rationale: Rationale for Correct Answer (D):
The correct answer is D because muscle weakness is a potential sign of digoxin toxicity. It is crucial for the client to notify the provider immediately to prevent serious complications. This statement indicates an understanding of the teaching regarding digoxin therapy.
Summary of Incorrect Choices:
A: Incorrect. Taking digoxin with a pulse less than 50 beats per minute can lead to bradycardia and toxicity.
B: Incorrect. Taking digoxin with fiber may decrease its absorption, reducing its effectiveness.
C: Incorrect. Blurred vision is a sign of digoxin toxicity, and the dose should be decreased, not increased.
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 best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (A) may not guarantee accurate communication. Familiarizing with sign language (C) may not be sufficient for complex medical discussions. Using a board with pictures (D) may not be effective for detailed conversations.
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. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries.'
- B. I often have diarrhea after eating scrambled eggs.'
- C. I have trouble breathing if I eat acidic foods.'
- D. I sometimes start to wheeze when I eat peanuts.'
Correct Answer: D
Rationale: The correct answer is D because wheezing after consuming peanuts indicates a potential allergic reaction, which could also extend to latex due to cross-reactivity. Peanuts and latex share similar proteins, leading to potential allergic responses. Choices A, B, and C do not indicate a direct correlation to latex allergy and are unrelated symptoms.