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The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client's voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The nurse should observe for muscle twitching and numbness or tingling of the lips, fingers, and toes in a client who had a thyroidectomy and is at risk for hypocalcemia. Hypocalcemia is a potential complication following thyroidectomy because the parathyroid glands may be inadvertently removed or damaged during the surgery, leading to decreased calcium levels in the blood. Symptoms of hypocalcemia include muscle twitching (especially in the face), and numbness or tingling around the lips, fingers, and toes. Prompt recognition of these symptoms is crucial as severe hypocalcemia can lead to more serious complications, such as seizures and laryngospasm. Monitoring for these signs allows the nurse to intervene early and prevent further complications.
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To whom is RhIG (RhoGAM) administered to prevent Rh isoimmunization?
- A. Rh-negative women who deliver an Rh-positive newborn
- B. Rh-positive women who deliver an Rh-negative newborn
- C. Rh-negative newborns whose mothers are Rh positive
- D. Rh-positive fathers before conception of second newborn when first newborn was Rh positive
Correct Answer: A
Rationale: RhIG (RhoGAM) is administered to Rh-negative women who deliver an Rh-positive newborn to prevent Rh isoimmunization. Rh isoimmunization can occur when an Rh-negative mother is exposed to Rh-positive fetal blood during childbirth, leading to the production of antibodies against Rh antigen. RhIG works by binding to and destroying any fetal Rh-positive red blood cells that have entered the mother's circulation, preventing her immune system from mounting an immune response and producing antibodies. This helps to protect subsequent pregnancies from complications related to Rh isoimmunization. Therefore, RhIG administration is crucial in preventing sensitization and ensuring the health of future pregnancies in Rh-negative women who deliver an Rh-positive newborn.
The most common symptom of JRA that causes a patient to seek medical attention is:
- A. joint swelling.
- B. limited movement.
- C. fatigue.
- D. pain.
Correct Answer: D
Rationale: The most common symptom of Juvenile Rheumatoid Arthritis (JRA) that causes a patient to seek medical attention is pain. Joint pain is a hallmark symptom of JRA and can range from mild discomfort to severe pain. This pain can be persistent or intermittent, and it often worsens with movement or activity. Pain is a significant factor that leads patients to seek medical evaluation in order to diagnose and manage their condition. While joint swelling, limited movement, and fatigue are also common symptoms of JRA, pain is typically the primary reason patients seek medical attention.
The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:
- A. Chronic liver failure.
- B. Pathologic bone fractures.
- C. Acute heart failure.
- D. Hypoxemia.
Correct Answer: B
Rationale: Clients with multiple myeloma are at increased risk for pathologic bone fractures due to the disease's effects on bone tissue. Multiple myeloma is a cancer of plasma cells, a type of white blood cell found in the bone marrow. The growth of abnormal plasma cells weakens the bone structure, leading to bone lesions and an increased risk of fractures. The bone lesions can cause pain, bone deformities, and complications such as hypercalcemia. Therefore, nurses caring for clients with multiple myeloma should prioritize interventions to prevent pathologic bone fractures and manage bone health.
Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
- A. Acyclovir (Zovirax)
- B. Varicella globulin
- C. Diphenhydramine hydrochloride (Benadryl)
- D. VCZ immune globulin (VariZIG)
Correct Answer: D
Rationale: VCZ immune globulin (VariZIG) is given to high-risk children after exposure to chickenpox to prevent varicella. VariZIG contains antibodies against the varicella-zoster virus, providing passive immunity to the child. This can help reduce the severity of the infection or prevent it altogether in high-risk individuals. Acyclovir (Zovirax) is an antiviral medication used to treat varicella infections but is not typically used for prevention post-exposure. Varicella globulin is not a treatment for varicella. Diphenhydramine hydrochloride (Benadryl) is an antihistamine and is not used for preventing varicella post-exposure.
The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
- A. The newborn's length and weight are the most accurate indicators of gestational age.
- B. The newborn's Apgar score and the mother's estimated date of confinement (EDC) are combined to determine gestational age.
- C. The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age.
- D. The newborn's chest circumference compared to the head circumference is the determinant for gestational age.
Correct Answer: C
Rationale: The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age. Assessment of posture at rest involves observing the newborn's flexed or extended posture when lying flat on their back. Premature infants tend to have more flexed postures due to their immature muscular tone. Arm recoil refers to the ability of the newborn to return their extended arm flexes to the flexed position. This reflex is typically present in more mature infants. These physical signs, along with other factors such as skin texture, breast development, and ear formation, are used by healthcare providers to estimate the gestational age of newborns. While length, weight, and head circumference are also important measurements, the posture at rest and arm recoil are specifically used in determining gestational age.