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Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.
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A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
- A. States feels better after talking with family and friends
- B. Consumes high-carbohydrate foods when stressed
- C. Dislikes the support group meetings
- D. Spends most of the day in bed
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.
Mr. Santos a 59-year old businessman was diagnosed with angina pectoris. The nurse understands that the cause of angina pectoris is:
- A. decrease in the alveolar surface for gas exchange
- B. inadequate supply of oxygen to the myocardium
- C. inadequate blood pressure in the pulmonary circulation
- D. increase in the alveolar surface for gas exchange
Correct Answer: B
Rationale: The correct answer is B: inadequate supply of oxygen to the myocardium. Angina pectoris is chest pain or discomfort caused by reduced blood flow to the heart muscle. This lack of oxygenated blood supply to the myocardium leads to ischemia, resulting in the characteristic chest pain. Choice A is incorrect as it refers to a decrease in alveolar surface area for gas exchange, which is related to conditions like emphysema, not angina. Choice C is incorrect as it pertains to pulmonary circulation, not coronary circulation. Choice D is incorrect as an increase in alveolar surface area would not be a cause of angina pectoris.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.
During the evaluation phase, what key action does the nurse perform?
- A. Diagnose the client’s condition based on new information.
- B. Identify nursing interventions for client care.
- C. Determine the effectiveness of the care plan.
- D. Develop goals and outcomes for client care.
Correct Answer: C
Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately.
Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.