Nokea
The nurse observes the client as he walks into the room. What information will this provide the nurse?
- A. Information regarding the client’s gait
- B. Information regarding the client’s personality
- C. Information regarding the client’s psychosocial status
- D. Information on the rate of recovery from surgery
Correct Answer: A
Rationale: The correct answer is A because observing the client's gait while walking can provide valuable information about their physical mobility, balance, coordination, and any potential musculoskeletal issues. This assessment helps the nurse determine if the client requires any assistance, mobility aids, or further evaluation by a healthcare provider. Choices B and C are incorrect as observing gait does not directly provide information on personality or psychosocial status. Choice D is incorrect as gait observation is not specifically related to the rate of recovery from surgery. In summary, observing the client's gait is important for assessing physical mobility and identifying potential issues, making it the most relevant choice in this context.
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For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
- A. Increased weight, hypertension, and insomnia
- B. Vaginal bleeding, jaundice, and inflammation
- C. Stupor, breast lumps, and pain
- D. Dyspnea, numbness, and headache
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
- A. Esophageal carcinoma
- B. Laryngeal carcinoma
- C. Pituitary carcinoma
- D. Colorectal carcinoma
Correct Answer: C
Rationale: After a transsphenoidal adenohypophysectomy, hormone replacement therapy is needed due to the removal of the pituitary gland. This surgery is typically done to treat pituitary carcinoma, making choice C the correct answer. Pituitary carcinoma is a type of cancer that affects the pituitary gland. Choices A, B, and D are incorrect because they do not involve the pituitary gland. Esophageal carcinoma affects the esophagus, laryngeal carcinoma affects the larynx, and colorectal carcinoma affects the colon and rectum. Therefore, the correct choice, C, is the only one related to the pituitary gland and the procedure described.
A patient is treated with IV methylprednisolone (Solu-medrol) for emphysema. What is the purpose of corticosteroid treatment in lung disease?
- A. Dry secretions
- B. Improve the oxygen-carrying capacity
- C. Treat the infection that causes an of hemoglobin.
- D. Reduce airway inflammation.
Correct Answer: D
Rationale: The correct answer is D: Reduce airway inflammation. Corticosteroids like methylprednisolone are used in emphysema to reduce inflammation in the airways, which can help improve lung function and symptoms. Corticosteroids work by suppressing the immune response that leads to inflammation in the airways. This can help decrease swelling, mucus production, and constriction of the airways, all of which contribute to the symptoms of emphysema. Dry secretions (choice A) and improving oxygen-carrying capacity (choice B) are not the primary purposes of corticosteroid treatment in emphysema. Treating infection that causes a low level of hemoglobin (choice C) is not relevant to corticosteroid treatment for emphysema.
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
- A. To gather data about a specific and current health problem.
- B. To identify life-threatening problems that require immediate attention.
- C. To compare and contrast current health status to baseline data.
- D. To establish a database to identify problems and strengths.
Correct Answer: D
Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay.
Explanation of other options:
A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database.
B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems.
C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose