Nokea
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply.
- A. Hearing loss.
- B. Visual disturbance.
- C. Headache.
- D. Orthopnea.
- E. Gout.
- F. Weight loss.
Correct Answer: B,C,D,E
Rationale: Polycythemia vera increases blood viscosity and red cell mass, leading to complications like visual disturbances (due to retinal hemorrhage), headaches (from hypertension or thrombosis), orthopnea (from heart failure), and gout (from increased uric acid due to cell turnover). Hearing loss and weight loss are not typical complications.
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The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
A 62-year-old male client with prostate cancer is scheduled for a radical prostatectomy. He expresses concern about how the surgery will affect his sexual function. The nurse's best response is to:
- A. Explain that sexual function will not be affected.
- B. Discuss that erectile dysfunction is a possible side effect.
- C. Suggest that he avoid sexual activity post-surgery.
- D. Assure him that libido will return immediately after recovery.
Correct Answer: B
Rationale: Radical prostatectomy often affects the nerves responsible for erections, making erectile dysfunction a possible side effect. Discussing this honestly prepares the client for potential outcomes and management options.
A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours as needed for pain. The medication is administered in relatively small doses primarily because it is:
- A. Less likely to cause dependency in small doses.
- B. Less irritating to subcutaneous tissues in small doses.
- C. As potent as most other analgesics in larger doses.
- D. Excreted before accumulating in toxic amounts in the body.
Correct Answer: C
Rationale: Hydromorphone is a potent opioid, effective in small doses, reducing the need for larger doses that increase side effect risks.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following?
- A. Tachycardia.
- B. Weight gain.
- C. Diarrhea.
- D. Nausea.
Correct Answer: B
Rationale: Hypothyroidism causes a slowed metabolism, leading to weight gain. Tachycardia, diarrhea, and nausea are more associated with hyperthyroidism.