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During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?
- A. Right upper quadrant pain
- B. Left lower quadrant pain
- C. Generalized abdominal pain
- D. Epigastric pain
Correct Answer: A
Rationale: The correct answer is A: Right upper quadrant pain. Cholecystitis is inflammation of the gallbladder, typically caused by gallstones. The gallbladder is located in the right upper quadrant of the abdomen, so pain in this area is a common symptom. The pain may also radiate to the back or right shoulder. Choices B, C, and D are incorrect because they do not typically align with the specific location of the gallbladder or the characteristic pain associated with cholecystitis.
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A client with acute pancreatitis is experiencing severe abdominal pain. Which enzyme level should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: A
Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis.
Incorrect choices:
B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis.
C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase.
D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.
What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fiber diet.
- C. Clean the perianal area carefully after every bowel movement.
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: The correct answer is C: Clean the perianal area carefully after every bowel movement. This is important to prevent skin breakdown and infection due to the potential side effect of radiation-induced diarrhea. By maintaining good hygiene in the perianal area, the patient can reduce the risk of complications such as skin irritation and infection.
Choice A is incorrect because testing stools for the presence of blood is not directly related to preventing complications from external-beam radiation.
Choice B is incorrect because while a high-residue, high-fiber diet may be beneficial for some cancer patients, it is not specifically recommended to prevent complications from radiation therapy in this case.
Choice D is incorrect because inspecting the mouth and throat daily for thrush is more relevant for patients receiving chemotherapy or immunosuppressive therapy, not specifically for those undergoing external-beam radiation.
A patient with hyperthyroidism is to receive radioactive iodine therapy. What information should the nurse include in the patient teaching plan?
- A. Avoid close contact with pregnant women for one week.
- B. Take iodine supplement daily.
- C. Restrict fluid intake to 1 liter per day.
- D. Use disposable utensils for all meals.
Correct Answer: A
Rationale: The correct answer is A. The rationale is that radioactive iodine therapy can harm a developing fetus, so patients should avoid close contact with pregnant women for one week. Choice B is incorrect as iodine supplements can interfere with the therapy. Choice C is incorrect as fluid intake should not be restricted unless specifically advised by the healthcare provider. Choice D is incorrect as there is no need to use disposable utensils for all meals.
What is the most appropriate nursing intervention to help alleviate severe abdominal pain in a patient with acute pancreatitis?
- A. Encourage oral intake of clear fluids.
- B. Place the patient in a supine position.
- C. Administer prescribed opioid analgesics.
- D. Apply a heating pad to the abdomen.
Correct Answer: C
Rationale: The correct answer is C, administering prescribed opioid analgesics. This intervention is appropriate for severe abdominal pain in acute pancreatitis as opioids are effective in managing pain. Encouraging oral intake (A) can worsen symptoms, a supine position (B) can exacerbate pain, and a heating pad (D) can aggravate inflammation. Administering opioid analgesics provides direct pain relief and is the most effective intervention for alleviating severe abdominal pain in acute pancreatitis.
A patient is admitted with a diagnosis of myasthenia gravis. What symptom should the nurse expect to find during the assessment?
- A. Joint pain
- B. Muscle weakness
- C. Loss of sensation
- D. Severe headache
Correct Answer: B
Rationale: The correct answer is B: Muscle weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on acetylcholine receptors at the neuromuscular junction. This leads to impaired muscle contraction and weakness, especially in the face, neck, and extremities. Joint pain (A) is not a typical symptom of myasthenia gravis. Loss of sensation (C) is more indicative of a sensory nerve disorder rather than a motor disorder like myasthenia gravis. Severe headache (D) is not a common symptom of myasthenia gravis; it is more likely to be associated with other conditions such as migraines or intracranial pathology.