Nokea
The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The most likely cause of her chief complaint this morning is a frequent complication of the hypophysectomy. A hypophysectomy is the surgical removal of the pituitary gland. One common complication following a hypophysectomy is diabetes insipidus, characterized by polyuria (excessive urination) and polydipsia (excessive thirst). This occurs because the removal of the pituitary gland can disrupt the regulation of antidiuretic hormone (ADH), which plays a key role in maintaining water balance in the body. Therefore, it is the most likely cause of the patient's chief complaint of polyuria this morning.
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When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
- A. Pulse, respirations, temperature
- B. Temperature, pulse, respirations
- C. Respirations, temperature, pulse
- D. Respirations, pulse, temperature
Correct Answer: A
Rationale: When performing a newborn assessment, it is important to measure the vital signs in the sequence of pulse, respirations, and temperature. This sequence is recommended because measuring the pulse first provides immediate information on the baby's cardiovascular status, followed by respirations to assess respiratory function, and ending with temperature which can be influenced by the other vital signs. This comprehensive approach helps ensure all vital signs are assessed accurately and in a logical order.
Which of the ff nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest c.Elevate the clients head
- B. Administer a prescribed anti pyretic
- C. Administer supplemental oxygen
Correct Answer: C
Rationale: Administering supplemental oxygen is the most appropriate nursing intervention to relieve tachycardia that may develop in a client with myocarditis from hypoxemia. Myocarditis can lead to decreased oxygen delivery to the tissues, which may result in tachycardia as the body tries to compensate for the lack of oxygen. Providing supplemental oxygen will help increase oxygen levels in the blood, improving tissue perfusion and thus reducing the tachycardia. This intervention aims to address the underlying cause of the tachycardia in this situation.
The nurse assesses for the characteristic movement of Parkinson's disease which is a (n):
- A. Exaggerated muscle flaccidity that leads to frequent falls
- B. Hyperextension of the back and neck that alters normal movements
- C. Pronation- supination of the hand and forearm that interferes with normal hand activities
- D. Combination of all of the above
Correct Answer: D
Rationale: The characteristic movement of Parkinson's disease is the pronation-supination of the hand and forearm, also known as the "pill-rolling" tremor. This movement interferes with normal hand activities and is a common early sign of Parkinson's disease. Exaggerated muscle flaccidity leading to frequent falls and hyperextension of the back and neck are not typically associated with Parkinson's disease.
An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?
- A. Nearly two-thirds of client with diabetes mellitus are over age
Correct Answer: A
Rationale: Diabetes mellitus is a chronic condition that affects people of all ages, but the prevalence increases with age. As people get older, their risk of developing type 2 diabetes mellitus also increases. Research has shown that nearly two-thirds of individuals with diabetes are over the age of 60. Age is a significant risk factor for developing diabetes, especially type 2 diabetes, which is more common in older individuals. Therefore, the statement "Nearly two-thirds of clients with diabetes mellitus are over the age of 60" is true.
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: Bacon contains the highest kilocalories among the food choices provided. Bacon is high in fat, with approximately 42 kilocalories per slice (8 grams) compared to other options like an apple (52 kilocalories), chicken (231 kilocalories), and bread (79 kilocalories). The high fat content in bacon contributes to its higher caloric value compared to the other choices listed. As such, bacon is the food choice with the highest kilocalorie content in this selection.