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Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
- A. Prevent tension on the suture.
- B. Monitor urine for glucose and acetone.
- C. Encourage oral fluids, and monitor intake and output.
- D. Encourage coughing and deep breathing every hour.
Correct Answer: A
Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.
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A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?
- A. Apply ointment to the skin to avoid moisture
- B. Wash the area gently with water and pat dry
- C. Use a mild antiseptic soap to wash the area and pat dry
- D. Apply talcum powder to keep the skin dry
Correct Answer: B
Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.
A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:
- A. The legs extended and rotated internally; the elbow, wrists, and fingers flexed
- B. The legs pulled toward the chest; the head bent back at a 30-degree angle
- C. The back arched; the arms and legs extended and rigid
- D. The legs extended and rotated externally; the head turned to the right or the left
Correct Answer: A
Rationale: Decorticate posturing is indicative of an injury to the corticospinal tract, resulting in abnormal posturing. It may occur spontaneously or in response to stimulation. This posture involves the legs being extended and rotated internally, while the elbows, wrists, and fingers are flexed inward. Choice A is correct because it accurately describes the expected positioning associated with decorticate posturing. Choices B, C, and D are incorrect. Choice B describes a different type of posturing known as opisthotonos. Choice C describes an exaggerated arching of the back, which is not characteristic of decorticate posturing. Choice D describes a different type of posturing with external rotation of the legs and head turning to the side, not consistent with decorticate posturing.
A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication?
- A. A decrease in muscle spasticity and involuntary movements
- B. A slowed progression of Multiple Sclerosis-related plaques
- C. A decrease in the length of the exacerbation
- D. A stabilization of mood and sleep
Correct Answer: C
Rationale: Methylprednisolone infusion is the first-line treatment during an acute exacerbation of Multiple Sclerosis. It is used to decrease the length and severity of a relapse by reducing inflammation in the central nervous system. Choice A, 'A decrease in muscle spasticity and involuntary movements,' is incorrect because methylprednisolone primarily targets inflammation and does not directly address muscle spasticity. Choice B, 'A slowed progression of Multiple Sclerosis-related plaques,' is incorrect as methylprednisolone is not used to slow the progression of the disease but rather to manage acute exacerbations. Choice D, 'A stabilization of mood and sleep,' is not an expected outcome of methylprednisolone administration for Multiple Sclerosis exacerbation as it primarily targets the inflammatory process associated with the relapse.
A patient diagnosed with epilepsy is receiving discharge education from a nurse. Which of the following teachings should be emphasized the most?
- A. Avoid consuming alcohol and drugs
- B. Adhere to follow-up appointments with the neurologist, physician, or other healthcare provider as directed
- C. Continue taking anticonvulsants, even if seizures have ceased
- D. Wear a medical alert bracelet or carry an ID card indicating epilepsy
Correct Answer: C
Rationale: The most critical teaching that the nurse should stress to a patient with epilepsy is to continue taking anticonvulsants even if seizures have stopped. Suddenly stopping antiepileptic drugs can lead to seizures and an increased risk of status epilepticus, a life-threatening condition. Choice A, advising to avoid alcohol and drugs, is important but not as crucial as maintaining anticonvulsant therapy. Choice B, emphasizing follow-up appointments, is essential but ensuring medication compliance is more critical to prevent seizure recurrence. Choice D, wearing a medical alert bracelet, is important for emergency identification but does not directly impact the patient's immediate safety like medication adherence does.
The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?
- A. Polyuria
- B. Weight gain
- C. Hypotension
- D. Grossly bloody urine
Correct Answer: B
Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.