Nokea
The client has surgery for removal of a prolactinoma. Which of the following interventions would be appropriate for this client?
- A. Place the client in Trendelenburg position for postural drainage.
- B. Encourage coughing and deep breathing every two hours.
- C. Elevate the head of the bed 30°.
- D. Encourage the client to gently blow the nose every two hours to remove secretions.
Correct Answer: C
Rationale: After prolactinoma surgery (transsphenoidal hypophysectomy) elevating the head of the bed 30° reduces intracranial pressure and prevents cerebrospinal fluid leakage. Trendelenburg position coughing and nose blowing may increase pressure or disrupt the surgical site.
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The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. An asthma attack
- C. Pneumonia
- D. Pulmonary embolus
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?
- A. Iron-deficiency anemia
- B. Sexually transmitted disease (STD)
- C. Intrauterine growth retardation
- D. Pregnancy-induced hypertension (PIH)
Correct Answer: D
Rationale: Iron-deficiency anemia can occur throughout pregnancy and is not age related. STDs can occur prior to or during pregnancy and are not age related. Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.