Nokea
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: Inability to move the affected leg after a lumbar microdiskectomy could indicate a serious complication such as nerve damage or postoperative hematoma putting pressure on the nerves. This is a critical issue that should be reported to the physician immediately for proper evaluation and management to prevent further complications or permanent damage. The other options, such as incisional pain, bleeding on the dressing, or muscle spasm, are common postoperative issues that may not require immediate medical attention unless they are severe or persistent.
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A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic's standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. "There is no guarantee that I won't contract an STD if I choose to be sexually active."
- B. "Abstinence is the only sure way to avoid an STD."
- C. "If I use a condom with spermicide, I will be safer than if I don't use one."
- D. "If I question my partner about past sexual encounters, I can avoid STDs."
Correct Answer: D
Rationale: The statement "If I question my partner about past sexual encounters, I can avoid STDs" indicates a need for additional instruction. While communication with a partner about sexual history is important, relying solely on questioning a partner is not a foolproof method of avoiding STDs. Some individuals may not disclose their complete sexual history or may be unaware that they have an STD. It is crucial to emphasize the importance of using protection such as condoms consistently and correctly, getting tested regularly, and practicing safe sex in general.
The MOST appropriate advice for a 4-year-old child visiting the outpatient department with excessive crying is
- A. reassures her that this is a normal phenomenon
- B. seek more history regarding other skills and developmental domains
- C. refer her to pediatric psychiatry
- D. investigate for child abuse
Correct Answer: B
Rationale: Further history may help differentiate normal behavior from developmental concerns.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: B
Rationale: - **Encourage a liberal fluid intake (B):** It is essential to maintain hydration after a lumbar puncture to help prevent or alleviate a headache, which may occur due to a decrease in cerebrospinal fluid (CSF) pressure. Adequate hydration can help reduce the chances of a post-lumbar puncture headache.
Which combination of signs is commonly associated with glomerulonephritis?
- A. Mild proteinuria, hematuria, decreased urine output, and lethargy.
- B. Massive proteinuria, hematuria, increased output, and lethargy.
- C. Mild proteinuria, increased output, and lethargy.
- D. Massive proteinuria, decreased output, and hypotension.
Correct Answer: A
Rationale: Glomerulonephritis typically presents with mild to moderate proteinuria, hematuria, decreased urine output, and lethargy.
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: According to the guidelines by the American Heart Association (AHA), the patient's blood pressure readings of 164/102 and 176/100 on two separate occasions fall in the Stage 2 hypertension category. Stage 2 hypertension is defined as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher. The readings provided are significantly above these thresholds, indicating severe hypertension that requires prompt medical attention and management to reduce the risk of complications such as heart disease, stroke, and kidney damage. It is important for healthcare providers to closely monitor and intervene in cases of Stage 2 hypertension to prevent further health complications.