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When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
- A. low back pain
- B. urinary frequency
- C. GI distress
- D. malaise
Correct Answer: B
Rationale: Urinary frequency is least indicative of UTI during pregnancy. It is a common minor discomfort of pregnancy caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are usually no problems. Frequency may return in the third trimester when the uterus drops into the pelvic cavity. UTI symptoms include low back pain, suprapubic discomfort, and malaise, and are confirmed by laboratory findings. Low back pain, GI distress, and malaise are more closely associated with UTI during pregnancy compared to urinary frequency.
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Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?
- A. metoclopramide (Reglan)
- B. ondansetron (Zofran)
- C. hydroxyzine (Vistaril)
- D. prochlorperazine (Compazine)
Correct Answer: B
Rationale: Zofran is a serotonin antagonist commonly used to relieve nausea and vomiting by blocking serotonin receptors. Metoclopramide (Reglan) acts on dopamine receptors, hydroxyzine (Vistaril) is an antihistamine, and prochlorperazine (Compazine) is a dopamine antagonist. While these medications can also be used for nausea and vomiting, they do not primarily function as serotonin antagonists like ondansetron.
Which of the following is not a primary function of the kidneys?
- A. blood pressure control
- B. vitamin D activation
- C. erythropoietin production
- D. reabsorption of waste products
Correct Answer: D
Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.
The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?
- A. irregular respirations
- B. abdominal respirations
- C. shallow respirations
- D. 70 breaths per minute
Correct Answer: D
Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.
The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?
- A. Hypocalcemia.
- B. Hyponatremia.
- C. Hyperkalemia.
- D. Hypophosphatemia.
Correct Answer: A.
Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.
The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?
- A. Anxiety related to loss of vision and potential failure to regain vision.
- B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
- C. Acute pain related to tissue injury and decreased circulation to the eye.
- D. Risk for infection related to the eye injury.
Correct Answer: A
Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.