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A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
- A. It is caused by the lack of production of aldosterone by the adrenal gland.
- B. It is caused by a viral infection.
- C. It is caused by the overproduction of cortisol.
- D. It is caused by an autoimmune disorder.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Addison's disease is characterized by adrenal insufficiency.
2. Aldosterone is a hormone produced by the adrenal gland that helps regulate blood pressure and electrolyte balance.
3. Lack of aldosterone production in Addison's disease leads to electrolyte imbalances and low blood pressure.
4. Therefore, the correct answer is A as the lack of aldosterone production by the adrenal gland is the primary cause of Addison's disease.
Summary of other choices:
B. Addison's disease is not caused by a viral infection, so this choice is incorrect.
C. Addison's disease is not caused by the overproduction of cortisol, as it is associated with cortisol deficiency.
D. The most common cause of Addison's disease is an autoimmune disorder where the body attacks the adrenal glands, leading to their dysfunction.
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A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Vaccination against hepatitis B and C is recommended.
- C. Wash hands thoroughly after using the restroom.
- D. Food should be prepared with purified water.
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus. Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis. Choice B is incorrect as there is no vaccination available for hepatitis C. Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
- A. Artificial lubrication can be used to treat vaginal itching and dryness.
- B. Avoid sexual activity for the first 6 months.
- C. Use a menstrual pad for vaginal bleeding.
- D. Use a diaphragm for contraception.
Correct Answer: A
Rationale: The correct answer is A: Artificial lubrication can be used to treat vaginal itching and dryness. The rationale for this is that after a total abdominal hysterectomy and bilateral salpingo-oophorectomy, there is a decrease in estrogen levels, leading to vaginal dryness and itching. Using artificial lubrication can help alleviate these symptoms and improve comfort.
Choice B is incorrect as there is no need to avoid sexual activity for 6 months unless specifically advised by the healthcare provider. Choice C is incorrect as there should not be vaginal bleeding after a total abdominal hysterectomy. Choice D is incorrect as using a diaphragm for contraception is not recommended after a hysterectomy.
A nurse teaches a client about cervical polyps. What is an expected symptom?
- A. Pelvic pain
- B. Heavy menstrual bleeding
- C. Postcoital bleeding
- D. Urinary incontinence
Correct Answer: C
Rationale: The correct answer is C: Postcoital bleeding. Cervical polyps are benign growths on the cervix that can cause postcoital bleeding due to contact with the polyp during intercourse. Pelvic pain, heavy menstrual bleeding, and urinary incontinence are not typical symptoms of cervical polyps. Pelvic pain may occur in other conditions like endometriosis. Heavy menstrual bleeding can be a symptom of fibroids or hormonal imbalances. Urinary incontinence is more commonly associated with pelvic floor disorders or urinary tract infections. Postcoital bleeding specifically points to cervical polyps as the likely cause.
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
- A. Provide frequent oral and nares care.
- B. Monitor the client's oxygen levels.
- C. Administer intravenous antibiotics.
- D. Remove the tube immediately after 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has a wound infection and is on antibiotics.
- B. The client who has gastroenteritis and is febrile.
- C. The client who is receiving IV fluids and is in pain.
- D. The client who is on a clear liquid diet and has hypokalemia.
Correct Answer: B
Rationale: The correct answer is B. The client with gastroenteritis and fever is at risk for fluid volume deficit due to increased fluid loss from vomiting and diarrhea. Fever also increases fluid loss through perspiration. The other choices do not directly indicate increased fluid loss. A: Antibiotics for wound infection may not directly lead to fluid volume deficit. C: IV fluids would help maintain hydration status, so this client is not at risk for deficit. D: Hypokalemia may be related to electrolyte imbalance, but not necessarily fluid volume deficit.