Nokea
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Bowel management
- C. Sexual activity
- D. . All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.
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When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.
The nurse is caring for a client with type I diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
- A. I.M. or subcutaneous glucagon.
- B. I.V. bolus of dextrose 50%.
- C. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
- D. 10 U of fast-acting insulin.
Correct Answer: C
Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia.
Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation.
Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
- A. Fluoxymesterone (Halotestin)
- B. Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex])
- C. Tamoxifen (Nolvadex)
- D. Megestrol (Megace)
Correct Answer: B
Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]). Fluorouracil is commonly used in chemotherapy for liver cancer to inhibit cancer cell growth. It is a pyrimidine analog that interferes with DNA synthesis. Fluoxymesterone (A) is an androgen used in hormone replacement therapy, not in liver cancer treatment. Tamoxifen (C) is an antiestrogen used in breast cancer treatment, not liver cancer. Megestrol (D) is a progestin used in hormone therapy for breast cancer and endometrial cancer, not liver cancer. Therefore, the correct choice is B as it directly targets cancer cell growth in liver cancer treatment.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms.
Incorrect choices:
A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine.
B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.