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Clinical manifestations of Huntington’s disease include:
- A. Abnormal involuntary movements (chorea)
- B. Intellectual decline
- C. Emotional disturbances
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Abnormal involuntary movements are a hallmark feature, while cognitive decline and emotional disturbances are also commonly observed. Therefore, all three manifestations are typically present in individuals with Huntington's disease. Choices A, B, and C are incorrect because each of these symptoms alone does not encompass the full spectrum of clinical manifestations seen in Huntington's disease.
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When caring for a client diagnosed with a brain tumor of the parietal lobe, the nurse expects to assess:
- A. Short-term memory impairment.
- B. Seizures.
- C. Tactile agnosia.
- D. Contralateral homonymous hemianopia. Situation: The American cancer Society recommends routine screening to detect colorectal cancer.
Correct Answer: C
Rationale: The correct answer is C: Tactile agnosia. When assessing a client with a parietal lobe brain tumor, the nurse would expect to assess for tactile agnosia as the parietal lobe is responsible for processing sensory information, including touch and spatial awareness. Tactile agnosia is the inability to recognize objects by touch. This impairment is commonly associated with parietal lobe lesions. Short-term memory impairment (A) is more commonly associated with temporal lobe lesions. Seizures (B) are more commonly associated with frontal lobe lesions. Contralateral homonymous hemianopia (D) is associated with occipital lobe lesions. In summary, the parietal lobe tumor would likely manifest as tactile agnosia due to its role in sensory processing, making it the most relevant assessment finding in this scenario.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.
What common problem is related to outcome identification and planning?
- A. Failing to involve the client in the planning process
- B. Collecting sufficient data to establish a database
- C. Stating specific and measurable outcomes based on nursing diagnoses
- D. Writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting.
Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.
Which of the following is one of the discharge criteria from ambulatory surgery for patients following surgery?
- A. Able to drive self home
- B. IV narcotics given less than 30 minutes
- C. Has home telephone before discharge
- D. Understands discharge instructions
Correct Answer: D
Rationale: The correct answer is D: Understands discharge instructions. This is crucial for patient safety and recovery post-surgery. Understanding discharge instructions ensures patients know how to care for themselves at home, manage medications, recognize warning signs, and follow-up instructions. Choice A is incorrect as patients should not drive after surgery due to potential impairment. Choice B is incorrect as IV narcotics administration timing is not a discharge criterion. Choice C is irrelevant to the patient's readiness for discharge. Understanding discharge instructions is the key factor in ensuring the patient's well-being and recovery after ambulatory surgery.
A 68-year old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
- A. Diabetes mellitus
- B. Hypoparathyroidism
- C. Diabetes insipidus
- D. Hyperparathyroidism
Correct Answer: D
Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.