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The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?
- A. Hoarse voice.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Sore throat.
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent removal of parathyroid glands. Immediate intervention is necessary to prevent severe hypocalcemia symptoms like tetany and seizures. Hoarse voice (A) and difficulty swallowing (B) are expected post-thyroidectomy due to surgical trauma, while sore throat (D) is common from intubation.
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A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Tis refers to carcinoma in situ, meaning the cancer is limited to the surface layer of cells in the cervix.
2. N0 indicates no regional lymph node involvement.
3. M0 indicates no distant metastasis.
4. Therefore, the cancer is localized only to the cervix, making answer A correct.
Summary:
B: Incorrect - Does not address the staging information provided in Tis, N0, M0.
C: Incorrect - The staging information is already provided, and further testing may not be necessary at this stage.
D: Incorrect - Staging information does not indicate difficulty in determining the original site of the cancer.
An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer?
- A. Corticosteroids
- B. Gamma globulin
- C. Hepatitis B vaccine
- D. Fresh frozen plasma
Correct Answer: B
Rationale: The correct answer is B: Gamma globulin. Gamma globulin contains antibodies that can provide immediate passive immunity against hepatitis B virus. Administering corticosteroids (A) would not protect against hepatitis B infection. Hepatitis B vaccine (C) is used for prevention, not immediate protection. Fresh frozen plasma (D) does not contain specific antibodies against hepatitis B.
Prior to elective surgery, a patient taking warfarin should receive which instruction regarding warfarin therapy?
- A. Continue taking warfarin until the day of surgery.
- B. Stop taking warfarin three days before surgery.
- C. Switch to aspirin before surgery.
- D. Stop taking warfarin one week before surgery.
Correct Answer: D
Rationale: The correct answer is D because stopping warfarin one week before surgery reduces the risk of excessive bleeding during the procedure. Warfarin's anticoagulant effect can persist for several days, so stopping it earlier allows time for its effects to diminish. Choice A is incorrect because continuing warfarin until the day of surgery increases bleeding risk. Choice B is incorrect as stopping warfarin only three days before surgery may not provide enough time for the anticoagulant effect to wear off. Choice C is incorrect as aspirin is not a suitable substitute for warfarin in most cases.
A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?
- A. Administer regular insulin intravenously.
- B. Give oral hypoglycemic agents.
- C. Administer sodium bicarbonate.
- D. Provide a high-calorie diet.
Correct Answer: A
Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.
In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?
- A. Hepatic encephalopathy
- B. Hypoglycemia
- C. Electrolyte imbalance
- D. Dehydration
Correct Answer: A
Rationale: The correct answer is A: Hepatic encephalopathy. In liver cirrhosis, the liver's ability to detoxify ammonia is impaired, leading to elevated ammonia levels in the blood. This excess ammonia crosses the blood-brain barrier, causing neurological symptoms like confusion and disorientation. Hypoglycemia (B), electrolyte imbalance (C), and dehydration (D) can also contribute to altered mental status, but in a cirrhotic patient, hepatic encephalopathy is the most likely cause due to impaired ammonia metabolism.