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. After hypophysectomy, the pituitary gland is removed, leading to a deficiency in essential hormones. Patients will need lifelong hormone replacement therapy to maintain normal body functions. This is crucial for regulating metabolism, growth, reproduction, and stress response. Choices A, C, and D are incorrect because abnormal distribution of body hair, increased fluid intake, and repeat surgical procedures are not typically associated with hypophysectomy. It is essential to focus on the long-term management of hormone replacement therapy to ensure the patient's overall health and well-being.
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A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
- A. Raise the client’s head
- B. Place the client on a firm mattress
- C. Call the physician
- D. Administer an analgesic to relieve the pain
Correct Answer: C
Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.
Which of the ff instructions should a nurse give a client with non-Hodgkin’s lymphoma who is being treated with radiation and chemotherapy?
- A. Increase fluid intake
- B. Intake low-fat meals
- C. Intake soft, bland foods
- D. Intake food rich in folic acid
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake. This is important for a client undergoing radiation and chemotherapy for non-Hodgkin's lymphoma to prevent dehydration, help flush out toxins, and support kidney function. Increasing fluid intake can also help manage side effects like nausea and vomiting. Choices B, C, and D are incorrect because low-fat meals, soft bland foods, and foods rich in folic acid are not specifically indicated for clients undergoing radiation and chemotherapy for non-Hodgkin's lymphoma.
The adrenal cortex is responsible for producing which substances?
- A. Glucocortocoids and androgens
- B. Mineralocortiroids and
- C. Catecholamines and epinephrine catecholamines
- D. Norepinephine and epinephrine
Correct Answer: A
Rationale: The correct answer is A: Glucocorticoids and androgens. The adrenal cortex is divided into three layers, with the outer layer responsible for producing mineralocorticoids like aldosterone, the middle layer producing glucocorticoids like cortisol, and the inner layer producing androgens. Glucocorticoids are essential for regulating metabolism and immune response, while androgens are male sex hormones. Choices B, C, and D are incorrect because mineralocorticoids, catecholamines, norepinephrine, and epinephrine are produced by different parts of the adrenal gland, not specifically by the adrenal cortex.
Which of the following measures will not help correct the patient’s condition
- A. Offer large amount of oral fluid intake to replace fluid lost
- B. Give enteral or parenteral fluid
- C. Frequent oral care
- D. Give small volumes of fluid at frequent interval
Correct Answer: C
Rationale: Step-by-step rationale:
1. Providing oral care does not directly address fluid balance or hydration status.
2. Oral care focuses on maintaining oral hygiene and preventing infections.
3. Choices A, B, and D all involve fluid intake to address dehydration.
4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids.
Summary:
Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.