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If a client’s parathyroid glands were accidentally removed during a procedure, which condition should the nurse prepare for?
- A. Hypomagnesemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypocalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypocalcemia. The parathyroid glands regulate calcium levels in the body. Without them, calcium levels will drop, leading to hypocalcemia. A: Hypomagnesemia is incorrect because magnesium levels are not directly regulated by the parathyroid glands. B: Hyperkalemia and C: Hypernatremia are incorrect as they are not typically associated with parathyroid gland removal. In summary, the removal of parathyroid glands would result in hypocalcemia due to the disruption of calcium regulation in the body.
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In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: 3, 4, 2005. HIV can be transmitted through breast milk, blood, and semen due to the presence of the virus in these bodily fluids. Saliva, tears, and other body fluids do not typically contain enough of the virus to transmit HIV. Therefore, choices A, B, and D are incorrect as they include saliva, tears, and other non-transmissible fluids. It is crucial for the nurse to educate the patient on the modes of transmission to prevent the spread of HIV.
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
- A. Disturbed thought processes
- B. Related to
- C. Alzheimer’s disease
- D. Incoherent language
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: The correct answer is D: avoid caffeine, alcohol, and chocolate. This helps to reduce acid reflux symptoms associated with hiatal hernia. Caffeine, alcohol, and chocolate can relax the lower esophageal sphincter, leading to increased reflux. Elevating legs (choice A) does not address the underlying issue. Drinking more fluids (choice B) can exacerbate symptoms by increasing stomach volume. Increasing roughage (choice C) may worsen symptoms due to increased gastric distension. By avoiding triggers like caffeine, alcohol, and chocolate, the client can effectively manage her symptoms.
A patient returns from surgery ff. a TURP with a three-way Foley catheter and continuous bladder irrigation. Postoperative orders include Meperidine (Demerol) 75 mg IM q3h as needed for pain, belladonna and opium (B&O) suppository q4h as needed, and strict I&O. the patient complains of painful bladder spasms, and the nurse observes blood-tinged urine on the sheets. Which action should the nurse take?
- A. Give Demerol
- B. Give B&O suppository
- C. Warm the irrigation solution to body temperature
- D. Notify the physician stat
Correct Answer: D
Rationale: The correct action for the nurse to take is to notify the physician stat (choice D). Firstly, the patient presents with painful bladder spasms and blood-tinged urine, indicating a potential complication post-TURP. This warrants immediate medical attention to assess for possible bladder injury or hemorrhage. Giving Demerol (choice A) or B&O suppository (choice B) may provide symptomatic relief but does not address the underlying issue. Warming the irrigation solution (choice C) is not a priority in this situation and does not address the potential serious complications. Notifying the physician immediately allows for prompt evaluation and appropriate intervention to address the patient's condition effectively.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.