Nokea
The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?
- A. Acromegaly.
- B. Cushing's disease.
- C. Diabetes mellitus.
- D. Hypopituitarism.
Correct Answer: D
Rationale: Hypophysectomy can impair pituitary function, leading to hypopituitarism, with symptoms like fatigue, weakness, and hormonal deficiencies.
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A Stage II pressure ulcer is characterized by:
- A. Redness in the involved area.
- B. Muscle spasms in the involved area.
- C. Pain in the involved area.
- D. Tissue necrosis in the involved area.
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
The nurse develops a teaching plan for a client scheduled for a spinal fusion. Which of the following should the nurse expect to include?
- A. The client typically experiences more pain at the donor site than at the fusion site.
- B. The surgeon will apply a simple gauze dressing to the donor site.
- C. Neurovascular checks are unnecessary if the fibula is the donor site.
- D. The client's level of activity restriction is determined by the amount of pain.
Correct Answer: A
Rationale: The donor site (e.g., iliac crest) often causes more pain than the fusion site due to tissue trauma.
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
- A. Send freshly-collected urine samples to the laboratory.
- B. Return the remainder of the blood component unit to the blood bank.
- C. Return the intravenous administration set to the blood bank.
- D. Alert Risk Management about the incident.
- E. Report the incident to the Infection Control Manager.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.
Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.
A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which of the following statements by the nurse will be most helpful to the client?
- A. I have a special medication to decrease secretions.
- B. Avoid fluid intake 2 hours before sexual activity.
- C. Place a thin piece of gauze over the tracheostomy.
- D. Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity.
Correct Answer: C
Rationale: Placing a thin gauze over the tracheostomy can absorb secretions, reducing embarrassment and enabling the client to engage in sexual activity comfortably.