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The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
- A. Encourage the client to ask questions about personality sexuality
- B. Provide time for privacy
- C. Provide support for the spouse or significant other
- D. Suggest referral to a sex counselor or other appropriate professional
Correct Answer: D
Rationale: The correct answer is D: Suggest referral to a sex counselor or other appropriate professional. This is the most appropriate intervention as it addresses the client's concern about impotence affecting his marriage by offering specialized help from a professional who can provide counseling and guidance on managing sexual issues related to diabetes. Referring the client to a sex counselor ensures that he receives expert support in addressing his specific concerns and helps improve his overall well-being and quality of life.
A: Encouraging the client to ask questions about personality sexuality may not address the underlying issue of impotence and its impact on the marriage.
B: Providing time for privacy is important but may not directly address the client's concerns about impotence.
C: Providing support for the spouse or significant other is beneficial, but the primary focus should be on addressing the client's specific concerns about impotence.
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A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client’s platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: The correct answer is B: 20,000/ul. A platelet count below 20,000/ul puts the client at the highest risk for cerebral hemorrhage due to severe thrombocytopenia. Platelets are essential for blood clotting, and a low count increases the risk of spontaneous bleeding, especially in critical organs like the brain. Choices A, C, and D have platelet counts that are higher than the critical level of 20,000/ul, so they do not pose as high a risk for cerebral hemorrhage. Option D, 500/ul, is extremely low and would likely lead to severe bleeding, but the critical threshold for cerebral hemorrhage is considered to be around 20,000/ul.
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient’s sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: Step-by-step rationale:
1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination.
2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately.
3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits.
4. It also provides insight into the client's motor function and coordination abilities.
Summary:
- Choice B is incorrect because it focuses on sensory functions rather than motor functions.
- Choice C assesses fine motor skills, not grip strength and coordination.
- Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client’s urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: A
Rationale: The correct answer is A because bodily fluids and excretions (urine, feces, vomitus) can become contaminated with radiation from the implant. Therefore, they should be considered highly radioactive and handled appropriately.
Choice B is incorrect because the client may remain radioactive for a longer period than 10 days post-implant removal.
Choice C is incorrect because soiled linens should be handled according to radiation safety protocols and removed promptly.
Choice D is incorrect because bed rest is not necessary unless specifically indicated by the healthcare provider; the client should be encouraged to move around as tolerated to prevent complications.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.
After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
- A. Bleeding in the liver caused by the liver biopsy.
- B. Perforation of the colon caused by the liver biopsy.
- C. An allergic reaction to the contrast media used during liver biopsy.
- D. Normal post procedural pain, with a change in the level of consciousness resulting from the preexisting fever.
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention.
Incorrect options:
A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain.
C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion.
D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.