Nokea
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.
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A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication?
- A. Increase the amount of potassium in the diet.
- B. Maintain a regular program of weight-bearing exercise.
- C. Limit dietary vitamin D intake.
- D. Perform isometric exercises.
Correct Answer: B
Rationale: Weight-bearing exercise promotes bone density, counteracting bone resorption caused by excess cortisol in Cushing's disease.
Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
- A. Encourage the client to breathe shallowly.
- B. Have the client practice abdominal breathing.
- C. Offer the client inceptive spirit.
- D. Teach the client to splint the rib cage when coughing.
Correct Answer: D
Rationale: Splinting the rib cage during coughing stabilizes the chest, reducing pleuritic pain. Shallow breathing may worsen atelectasis. Abdominal breathing aids ventilation but not pain. 'Inceptive spirit' is likely a typo for incentive spirometry, which promotes lung expansion but not direct pain relief.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which of the following changes in her husband's behavior may confirm her fears?
- A. Increased decisiveness.
- B. Problem-focused coping style.
- C. Increase in social interactions.
- D. Disturbance in his sleep patterns.
Correct Answer: D
Rationale: Sleep disturbances are a common symptom of depression, suggesting the husband may be struggling emotionally with his wife's diagnosis.
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
- A. A limit of least 3,000 mL of fluid each day.
- B. Minimize daily activities.
- C. Keep urine alkaline to prevent urinary tract infections.
- D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
- E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.