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Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). This nerve is responsible for hearing and balance. Ringing noises indicate a disturbance in hearing function. The other choices are incorrect because: A: Frontal lobe is associated with executive functions, not hearing. B: Six cranial nerve (abducent) controls eye movement. C: Occipital lobe is related to vision, not hearing. Therefore, the correct choice is D as it directly relates to the symptom described.
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Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.
Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?
- A. keep an accurate record of intake and output.
- B. use nasal desmopressin acetate (DDAVP).
- C. be sure to get regular follow-up care.
- D. Be sure to exercise to improve cardiovascular fitness.
Correct Answer: C
Rationale: Step 1: Patients with Grave's disease who undergo thyroidectomy require regular follow-up care for monitoring thyroid hormone levels and overall health.
Step 2: Regular follow-up care ensures early detection of any complications or recurrence of the disease.
Step 3: Monitoring helps in adjusting medication doses and managing any potential side effects.
Step 4: Choice A is important but not specific to thyroidectomy for Grave's disease. Choice B is not typically used post-thyroidectomy. Choice D may be beneficial but not a priority compared to regular follow-up care.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Keep extremities at neutral position. This intervention promotes proper blood flow and reduces the risk of thrombophlebitis by preventing compression or restriction of blood vessels. Removing and reapplying elastic stockings (choice A) can disrupt circulation and increase the risk of thrombophlebitis. Changing the client's position (choice C) may not directly address hemostasis or thrombophlebitis. Using a flotation mattress (choice D) is not specifically focused on maintaining proper positioning of the extremities to promote circulation.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.
For a client in addisonian crisis, it would be very risky for a nurse to administer:
- A. potassium chloride.
- B. hydrocortisone.
- C. normal saline solution
- D. fludrocortisone.
Correct Answer: A
Rationale: The correct answer is A: potassium chloride. In Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone. Potassium levels are typically elevated in Addisonian crisis due to decreased aldosterone. Administering potassium chloride can further increase potassium levels, leading to life-threatening cardiac arrhythmias. Hydrocortisone (B) is essential to replace cortisol, normal saline solution (C) helps with volume resuscitation, and fludrocortisone (D) replaces aldosterone. Administering potassium chloride would exacerbate the hyperkalemia in Addisonian crisis.