Nokea
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 planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding indicates potential cardiac issues like myocardial infarction. Immediate follow-up is necessary to assess for any life-threatening conditions. The other options are not as urgent. A: Temperature within normal range, C: Respiratory rate slightly elevated but not critical, D: Elevated blood pressure but not as concerning as irregular heart rate.
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?'
- B. After this procedure, you will feel much better.'
- C. Tell me why you are scared to have this procedure.'
- D. Let's discuss your concerns about this procedure.'
Correct Answer: D
Rationale: Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce platelet aggregation and prevent further clot formation in clients with acute angina, thus reducing the risk of myocardial infarction. Administering aspirin should be the first action as it addresses the immediate risk of clot formation and helps improve blood flow to the heart muscle.
Measuring blood pressure (A) can be important but is not the priority in this situation. Administering nitroglycerin (C) is important for symptom relief but does not address the underlying cause. Initiating IV access (D) may be necessary later for further interventions, but it is not the first priority.
A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
- A. I would like to meet with another client who has had an amputation.
- B. I would rather not look at my stump during a dressing change.
- C. I am glad that I no longer have to deal with my infected leg.
- D. I understand that I will be unable to return to my job.
Correct Answer: A
Rationale: The correct answer is A: "I would like to meet with another client who has had an amputation." This statement indicates acceptance of the altered body image as the client is actively seeking connection with others who have gone through a similar experience. By expressing a desire to meet someone with a similar amputation, the client is acknowledging and normalizing their own situation, showing acceptance and readiness to engage in discussions about their body image.
Summary of why other choices are incorrect:
B: "I would rather not look at my stump during a dressing change." - This statement suggests avoidance and discomfort with the amputation, indicating a lack of acceptance.
C: "I am glad that I no longer have to deal with my infected leg." - While this statement may indicate relief from a health issue, it does not necessarily demonstrate acceptance of the altered body image.
D: "I understand that I will be unable to return to my job." - This statement reflects resignation to a limitation but does not directly address body