Nokea
The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach?
- A. There will be a large turban dressing around the skull after surgery.
- B. The client will not be able to eat for four (4) or five (5) days postop.
- C. The client should not blow the nose for two (2) weeks after surgery.
- D. The client will have to lie flat for 24 hours following the surgery.
Correct Answer: C
Rationale: Blowing the nose (C) risks disrupting the surgical site and causing CSF leaks after transsphenoidal surgery. Turban dressings (A) are not used, eating resumes sooner (B), and flat positioning (D) is not required.
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When the nursing team discusses the client's plan of care, which has the highest priority?
- A. Teaching the client about prevention of skin breakdown
- B. Strengthening the client's upper body muscles
- C. Confronting the client's denial of the prognosis
- D. Letting the client verbalize about the accident
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
The nurse assessed the client newly diagnosed with MG. Which finding should the nurse recognize as being unrelated to the diagnosis?
- A. Drooping eyelids
- B. Slurred speech
- C. Weak lower extremities
- D. Circumoral tingling
Correct Answer: D
Rationale: Ptosis (drooping eyelids) is a sign of muscle weakness often seen with MG. If the muscles involved with speech are weak in the client with MG, the client may exhibit slurred speech. Clients with MG may demonstrate weakness in the lower extremities. Numbness around the mouth is not associated with muscle weakness but could be indicative of a calcium deficiency or some other problem.
Which nursing action is best for controlling the symptoms of the client diagnosed with myasthenia gravis?
- A. Ensure that the client has regular bowel and bladder elimination.
- B. Administer each dose of medication at the precise scheduled time.
- C. Encourage the client to exercise twice daily for 30 minutes.
- D. Monitor the client's blood pressure every 4 hours.
Correct Answer: B
Rationale: Precise timing of pyridostigmine administration ensures consistent symptom control in myasthenia gravis by maintaining acetylcholine levels.
The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.