Nokea
Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
- A. Abnormal distribution of body hair
- B. Lifetime dependency on hormone replacement
- C. The need to drink many fluids to replace those lost
- D. The need to undergo repeat surgical procedures
Correct Answer: B
Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions.
A: Abnormal distribution of body hair is not directly related to hypophysectomy.
C: While fluid intake may be important post-surgery, it is not the primary focus of teaching.
D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues.
In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.
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. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?
- A. High corticotropin and low cortisol levels
- B. high corticotropin and high cortisol levels
- C. Low corticotropin and high cortisol levels
- D. Low corticotropin and low cortisol levels
Correct Answer: B
Rationale: Step-by-step rationale:
1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production.
2. High corticotropin levels would be expected due to the adenoma's overproduction.
3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands.
4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer.
Summary:
- Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma.
- Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma.
- Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications.
Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
- A. Reassess the client’s diet, medication, and lifestyle habits.
- B. Increase the client’s medication dosage.
- C. Document the elevated levels and continue with the current plan.
- D. Notify the client’s family about the lack of progress.
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue.
A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty.
B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition.
C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem.
In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Which of the following is the humoral immune response?
- A. B cells phagocytise the foreign antigen
- B. T cells are stimulated by B cells and turn into plasma cells, which produce antibodies or memory cells.
- C. B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.
- D. T cells produce antibodies.
Correct Answer: C
Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen.
Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies.
Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response.
Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.