Nokea
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
- A. Breast tenderness
- B. Increased facial hair
- C. Menstrual irregularities
- D. Hair loss
Correct Answer: C
Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.
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Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
- A. Ease the patient to the floor
- B. Insert a padded tongue depressor between his jaws
- C. Lift the patient and put him on the bed
- D. Restraint patient’s body movement
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.
A patient is diagnosed with Hashimoto’s thyroiditis and asks what causes it. The nurse would respond that the destruction of the thyroid in this condition is due to which of the following?
- A. Antigen-antibody complexes
- B. Viral infection
- C. Autoantibodies
- D. Bacterial infection
Correct Answer: C
Rationale: The correct answer is C: Autoantibodies. In Hashimoto's thyroiditis, the immune system mistakenly attacks the thyroid gland by producing autoantibodies against thyroid proteins such as thyroglobulin and thyroid peroxidase. These autoantibodies lead to inflammation and destruction of thyroid tissue. Antigen-antibody complexes (choice A) are not the main mechanism in Hashimoto's thyroiditis. Viral (choice B) and bacterial infections (choice D) do not directly cause autoimmune destruction of the thyroid in this condition. Autoantibodies targeting the thyroid gland are the key pathogenic factor in Hashimoto's thyroiditis.
Which of the following guidekines does not observe surgical asepisi in the operating room?
- A. sterile articles may touch other sterile articles or surface and remain sterile
- B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
- C. whenever a sterile barrier is breached, the area must be considered contaminated
- D. sterile drapes are used to create a sterile field
Correct Answer: A
Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.
A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client’s platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: The correct answer is B: 20,000/ul. A platelet count below 20,000/ul puts the client at the highest risk for cerebral hemorrhage due to severe thrombocytopenia. Platelets are essential for blood clotting, and a low count increases the risk of spontaneous bleeding, especially in critical organs like the brain. Choices A, C, and D have platelet counts that are higher than the critical level of 20,000/ul, so they do not pose as high a risk for cerebral hemorrhage. Option D, 500/ul, is extremely low and would likely lead to severe bleeding, but the critical threshold for cerebral hemorrhage is considered to be around 20,000/ul.
If a patient has severe hyperkalemia, it is possible to administer calcium gluconate intravenously to:
- A. Immediately lower the potassium level by
- B. Prevent transient renal failure (TRF)
- C. Accomplish all of the above
- D. Antagonize the action of K on the heart
Correct Answer: D
Rationale: Correct Answer: D. Antagonize the action of K on the heart
Rationale:
1. Calcium gluconate stabilizes cardiac cell membranes during hyperkalemia.
2. By antagonizing the effects of potassium on the heart, it helps prevent life-threatening cardiac arrhythmias.
3. It does not lower potassium levels immediately or prevent transient renal failure.
4. Administering calcium gluconate is specific to addressing the cardiac effects of hyperkalemia, not renal or overall potassium reduction.