Nokea
Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to
- A. Pass the catheter into the abdominal cavity
- B. Place the tubing into the urinary bladder
- C. Visualize abdominal organs for catheter placement
- D. Insert the catheter into the stomach
Correct Answer: A
Rationale: Pass the catheter into the abdominal cavity. The VP shunt drains cerebrospinal fluid into the peritoneal cavity via a catheter inserted through an abdominal incision.
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When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.
A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.
The client with multiple myeloma is admitted and prescribed cyclophosphamide (Cytoxan). During the treatment, the nurse should instruct the client to:
- A. Increase the fiber in his diet.
- B. Report hematuria.
- C. Avoid antacid consumption.
- D. Increase his activity.
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so reporting hematuria is critical. Fiber, antacids, and activity are not directly related to this medication's side effects.
A client is admitted with rheumatoid arthritis. Which symptoms, if exhibited by the client, are most consistent with the admitting diagnosis?
- A. A 72-year-old with pain, redness, and swelling in the big toes
- B. A 68-year-old with enlarged finger joints and pain in the knees
- C. A 34-year-old with joint pains and a red rash on the cheeks
- D. A 28-year-old with enlarged joints and painful muscles
Correct Answer: B
Rationale: Rheumatoid arthritis causes symmetrical joint inflammation, leading to enlarged, painful joints like fingers and knees. Toe pain suggests gout, rash suggests lupus, and muscle pain is less specific.