Nokea
A 62-year-old man who is scheduled for a total laryngectomy.
Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?
- A. We will need to learn other ways to communicate with each other.'
- B. My father will require a special kind of tube in his neck for his airway.'
- C. My husband will require a feeding tube for several months.'
- D. My dad may develop some difficulty with taste and smell after the surgery.'
Correct Answer: C
Rationale: Strategy: 'Further teaching is necessary' indicates an incorrect response. (1) will communicate in writing initially, then artificial larynx or esophageal speech (2) will require laryngectomy tube to prevent scar tissue contracture (3) correct-requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (4) common with total laryngectomy
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The nurse is caring for a client with a history of Addison’s disease.
- A. Which laboratory finding is most concerning for a client with Addison’s disease?
- B. Serum sodium of 128 mEq/L.
- C. Serum cortisol of 10 µg/dL.
- D. Blood glucose of 90 mg/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: A
Rationale: A serum sodium of 128 mEq/L indicates hyponatremia, a life-threatening complication in Addison’s disease due to aldosterone deficiency, risking shock. Low cortisol is expected, and normal glucose and potassium are unremarkable.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea.
Based on the nursing assessment, an appropriate priority nursing diagnosis is
- A. risk for constipation related to immobilization.
- B. risk for impaired skin integrity related to immobilization and secretions.
- C. risk for wound infection related to involuntary bowel secretions.
- D. risk for fluid volume excess related to secretions.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) constipation is not a problem because the client has diarrhea (2) correct-skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) there would be risk of fluid volume deficit due to diarrhea and secretions
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
- A. Para 2, Gravida 1
- B. Nulligravida 2, Para 1
- C. Primigravida 1, Para 1
- D. Gravida 2, Para 1
Correct Answer: D
Rationale: Gravida 2, Para 1. Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability.
A child admitted with failure to thrive has just had a positive sweat Test .
The nurse would anticipate which of the following changes in the child's plan of care initially?
- A. Administration of replacement enzymes.
- B. Administration of oxygen.
- C. A salt-restricted diet.
- D. Initiate intravenous therapy.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-sweat Test is a positive finding for cystic fibrosis (2) no data in this situation to indicate that the child is having pulmonary problems (3) salt is increased in diet (4) no need for IV therapy based on the data in situation