Nokea
The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?
- A. The client has a history of Type II diabetes.
- B. The client is on a continuous tube-feeding regimen.
- C. The client is on fluid restriction.
- D. The pharmacy has provided phenytoin in tablet form.
Correct Answer: B
Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.
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A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:
- A. climacteric
- B. menopause
- C. perimenopause
- D. postmenopause
Correct Answer: C
Rationale: Perimenopause refers to a period in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. It typically lasts around five years. In the case of the middle-aged woman experiencing irregular menses for six months, she aligns with perimenopause as it involves irregular menstrual cycles, one of the common symptoms during this transitional phase. Climacteric is a term describing the period of life with physiologic changes leading to the end of a woman's reproductive ability but not specifically characterized by irregular menses. Menopause marks the permanent cessation of menses and does not involve the transitional irregularities seen in perimenopause. Postmenopause is the phase after the completion of menopausal changes.
When assisting the physician in performing transillumination of a client's scrotum, how should the nurse prepare for this procedure?
- A. Obtaining a flashlight and darkening the room
- B. Instructing the client to drink three glasses of water
- C. Instructing the client to take several deep breaths and bear down
- D. Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments
Correct Answer: A
Rationale: When preparing for transillumination of the scrotum, the nurse should obtain a flashlight and darken the room. This is done to allow the strong flashlight to be shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not part of the preparation for this procedure. Additionally, it is not necessary to inform the client that the procedure is uncomfortable as transillumination is a painless procedure.
A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness, and desquamation every 8 hours
- C. explaining progression of the disease to the client and their family
- D. assessing heart sounds and rhythm
Correct Answer: C
Rationale: Explaining the progression of the disease to the client and their family is the most appropriate nursing measure to promote a positive body image. By educating them about when symptoms are expected to improve and resolve, they can understand that there will be no permanent disruption in physical appearance that could negatively impact body image. While administering immune globulin intravenously may be part of the treatment for Kawasaki disease, it does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly impact body image. Assessing heart sounds and rhythm is crucial for monitoring cardiac effects of Kawasaki disease but is not directly related to promoting a positive body image.
The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible
- B. taking care of the whole person"?body, mind, spirit, heart, and soul
- C. no interventions are needed because the client is near death
- D. supporting the needs of the family and client
Correct Answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.
When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct Answer: C
Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.