Nokea
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply.
- A. Increased heart rate
- B. Improved well-being
- C. Lowered blood pressure
- D. Increased respiratory rate
- E. Decreased muscle tension
- F. Increased neural impulses to the brain
Correct Answer: B,C,E
Rationale: Relaxation is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. Relaxation elongates the muscle fibers, reduces the neural impulses to the brain, and thus decreases the activity of the brain and other systems. The effects of relaxation therapy include improved well-being; lowered blood pressure, heart rate, and respiratory rate; decreased muscle tension; and reduced symptoms of distress in persons who need to undergo treatments, those experiencing complications from medical treatment or disease, or those grieving the loss of a significant other. This therapy does not cause an increased heart rate, increased respiratory rate, or increased neural impulses to the brain.
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The nurse creates a postoperative plan of care for a client scheduled for a hypophysectomy. Which interventions should be included in the plan of care? Select all that apply.
- A. Obtain daily weights.
- B. Monitor intake and output.
- C. Elevate the head of the bed.
- D. Use a soft toothbrush for mouth care.
- E. Encourage coughing and deep breathing.
Correct Answer: A,B,C
Rationale: A hypophysectomy is done to remove a pituitary tumor. Because temporary diabetes insipidus or syndrome of inappropriate antidiuretic hormone can develop after this surgery, obtaining daily weights and monitoring intake and output are important interventions. The head of the bed is elevated to assist in preventing increased intracranial pressure. Tooth-brushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy because of the risk of increasing intracranial pressure. These activities interfere with the healing of the incision and can disrupt the graft.
The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.
- A. Yellowish sclera
- B. Reports of severe fatigue
- C. Pink mucous membranes
- D. Increased vaginal secretions
- E. Reports of frequent headaches
- F. Reports of increased frequency of voiding
Correct Answer: B,E
Rationale: Iron deficiency anemia is described as a hemoglobin blood concentration of less than 10.5 to 11.0 g/dL (105 to 110 mmol/L). Complaints of headaches and severe fatigue are abnormal findings and may reflect complications of this type of anemia caused by the decreased oxygen supply to vital organs. Options 3, 4, and 6 are normal findings in the first trimester of pregnancy. Yellow sclera (whites of the eyes) is associated with jaundice.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.
A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?
- A. Rh incompatibility
- B. Fetal cardiomegaly
- C. The increase in circulating blood volume
- D. Hypertrophy and increased contractility of the heart
Correct Answer: C
Rationale: Pregnancy taxes the circulating system of every woman because the blood volume increases, which causes the cardiac output to increase. Stroke volume × heart rate = cardiac output (SV × HR = CO). Options 1, 2, and 4 are not directly associated with pregnancy in a client with a cardiac condition.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.