Nokea
Rehabilitation plans for Mr. Gabatan;
- A. Should be left up to Mr. Gabatan and his family
- B. Should be considered and planned for early in his care
- C. Are not necessary, because he will return to former activities
- D. Are not necessary, because he will probably not able to work again Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.
Correct Answer: B
Rationale: Rationale for Correct Answer B: Rehabilitation plans for Mr. Gabatan should be considered and planned for early in his care to optimize his recovery and quality of life. Planning early allows for tailored interventions to address his specific needs and goals, promoting better outcomes. Early rehabilitation can also prevent complications and improve functional abilities. By proactively addressing rehabilitation needs, Mr. Gabatan can have a smoother transition back to his daily activities.
Summary of Incorrect Choices:
A: Leaving the rehabilitation plans solely up to Mr. Gabatan and his family may not consider all aspects of his recovery and could lead to suboptimal outcomes.
C: Assuming that Mr. Gabatan will return to his former activities without a rehabilitation plan overlooks the individualized care needed for his recovery.
D: Dismissing the need for rehabilitation based on the assumption that he may not be able to work again is premature and does not account for potential improvements in his condition through appropriate rehabilitation interventions.
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Which of the ff. medications might be ordered to help control symptoms of multiple sclerosis, and possibly induce a remission?
- A. Acyclovir
- B. Thyrotropin
- C. ACTH
- D. Benadryl
Correct Answer: C
Rationale: Correct Answer: C - ACTH
Rationale:
1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation.
2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone.
3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission.
Summary of other choices:
A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis.
B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis.
D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Correct Answer: A - Cerebral edema
Rationale:
1. SIADH leads to water retention and dilutional hyponatremia.
2. Diuretic therapy aims to increase urine output and correct fluid imbalance.
3. If the client does not comply, excessive water retention can lead to cerebral edema.
4. Cerebral edema is a serious complication that can cause neurological deficits.
Summary:
- B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium.
- C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss.
- D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.
Which of the following is classified as subjective data in a nursing assessment?
- A. Heart rate of 90 beats per minute
- B. Client states, 'I feel nauseated.'
- C. Blood pressure of 130/80 mmHg
- D. Skin appears flushed
Correct Answer: B
Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly.
A, C, and D are incorrect:
A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed.
C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed.
D: Skin appears flushed is an objective observation that can be directly seen.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue).
Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, 'I am very nervous and scared to have surgery.' What client outcome is the priority?
- A. Evaluate the need for antibiotics.
- B. Resolve the client’s anxiety.
- C. Provide preoperative education.
- D. Prepare the client for surgery.
Correct Answer: B
Rationale: The correct answer is B: Resolve the client’s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.