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Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis caused by Neostigmine. Edrophonium HCL is a fast-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis. If the patient's weakness improves after administration of edrophonium, it indicates that the weakness was due to myasthenia gravis and not cholinergic crisis caused by excessive neostigmine. Choice A is incorrect because there is no synergestic effect between neostigmine and edrophonium. Choice B is incorrect as resistance to neostigmine is not a valid reason for ordering edrophonium. Choice D is incorrect because edrophonium is used for differential diagnosis, not for confirming the diagnosis of myasthenia gravis.
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A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Sexually transmitted disease
- C. Early onset of puberty
- D. Cryptorchidism
Correct Answer: D
Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, or undescended testicle, is a known risk factor for testicular cancer as the undescended testicle is more prone to developing cancerous changes. This condition increases the risk of testicular cancer even if the testicle is surgically corrected later in life. Other choices like A (Testosterone therapy during childhood) and B (Sexually transmitted disease) are not linked to testicular cancer. Choice C (Early onset of puberty) is not a direct risk factor for testicular cancer.
A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:
- A. Hair loss.
- B. Fatigue.
- C. Stomatitis.
- D. Vomiting.
Correct Answer: A
Rationale: The correct answer is A: Hair loss. Radiation therapy targets fast-growing cancer cells, which can also affect healthy cells such as those in hair follicles, leading to hair loss. This adverse effect occurs commonly with radiation therapy due to its impact on rapidly dividing cells. Hair loss is a well-known side effect that clients undergoing radiation therapy are often prepared for. The other choices, B: Fatigue, C: Stomatitis, and D: Vomiting, are also potential side effects of radiation therapy, but hair loss is specifically associated with radiation treatment due to its effect on hair follicles. Fatigue is a common side effect of cancer treatment in general, stomatitis is more commonly associated with chemotherapy, and vomiting can be a side effect of radiation but is not as directly linked as hair loss.
Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.
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 goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
- A. States feels better after talking with family and friends
- B. Consumes high-carbohydrate foods when stressed
- C. Dislikes the support group meetings
- D. Spends most of the day in bed
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.