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 correct answer is D because polyuria is a common complication following hypophysectomy (removal of the pituitary gland). This procedure can disrupt the regulation of antidiuretic hormone (ADH), leading to excessive urination. Choice A is incorrect as decreased stress would not cause polyuria. Choice B is unlikely as the onset of diabetes mellitus is not a typical immediate postoperative complication. Choice C is incorrect as removal of the pituitary gland would disrupt hormone regulation, possibly leading to polyuria, rather than being an expected result.
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A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
- A. Risk for impaired physical mobility due to surgery
- B. Ineffective denial related to poor coping mechanisms
- C. Disturbed body image related to the incision scar
- D. Risk of injury related to surgical outcomes
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance.
A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery.
B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client.
D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
- A. Poor control of blood glucose levels
- B. Current of recent foot trauma
- C. Inappropriate foot care
- D. Advanced age
Correct Answer: D
Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual.
Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time.
Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions.
Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Step 1: Safety First - The nurse's priority is patient safety. Without vital signs, medication administration can be unsafe.
Step 2: Accountability - The nurse must ensure accurate and timely vital signs recording before making clinical decisions.
Step 3: Delegation - Asking the NAP to record vital signs aligns with their role and helps maintain a reliable record.
Step 4: Proactive Approach - By having the NAP record vital signs, the nurse can make informed decisions based on accurate data.
Summary:
A: Incorrect - Proceeding with medications without vital signs can risk patient safety.
B: Incorrect - Waiting to review vital signs later can delay necessary interventions.
D: Incorrect - Omitting vital signs is negligent and compromises patient care.
The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for treating Parkinson's disease because it is converted to dopamine in the brain, replenishing the deficient dopamine levels in Parkinson's patients. Selegiline and Symmetrel are also used in treating Parkinson's, but they are typically used as adjunctive therapy rather than the primary treatment. Permax has been withdrawn from the market due to safety concerns, making it an incorrect choice.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.
Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.