Nokea
Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?
- A. "Have you noticed any pain in your legs when walking?"
- B. "Have you had any unexplained weight loss?"
- C. "Have you noticed any change in your bowel movements?"
- D. "Have you experienced any joint pain or discomfort?"
Correct Answer: B
Rationale: The correct answer is B: "Have you had any unexplained weight loss?" Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.
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Which instructions should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain that exacerbations will not occur in the summer
- B. Use nicotine gum to help quit smoking
- C. Wear extra warm clothing during cold exposure
- D. Avoid prolonged exposure to direct sunlight
Correct Answer: C
Rationale: The correct instruction for a client diagnosed with Raynaud's phenomenon is to wear extra warm clothing during cold exposure. This is essential in preventing vasospasms triggered by cold temperatures, which can worsen symptoms of Raynaud's phenomenon. Choice A is incorrect because exacerbations can occur in any season. Choice B is irrelevant and not directly related to managing Raynaud's phenomenon. Choice D is also incorrect as sunlight exposure does not significantly impact Raynaud's phenomenon.
Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client's medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client's symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client's symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.
The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish a rapport with the client to decrease embarrassment when assessing the site
- B. Encourage the client to lie in the lithotomy position twice a day
- C. Milk the tube inserted during surgery to allow the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood
Correct Answer: A
Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.
The system used at the division level and forward comprises six basic modules. Which module is composed of a dental officer, dental specialist, x-ray specialist, laboratory specialist, and needed equipment?
- A. Treatment squad
- B. Area support squad
- C. Medical service squad
- D. Dental squad
Correct Answer: D
Rationale: The correct answer is D, the Dental squad. This squad is specifically composed of a dental officer, dental specialist, x-ray specialist, laboratory specialist, and necessary equipment. The other choices, A, B, and C, do not include the specific group of specialists mentioned in the question. Therefore, they are incorrect. The Treatment squad may involve a broader range of medical professionals, while the Area support squad and Medical service squad focus on different aspects of healthcare support not related to the dental field.
The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:
- A. Astride one of her hips
- B. Strapped in an infant seat
- C. Wrapped tightly in a blanket
- D. Under the arm using a football hold
Correct Answer: A
Rationale: Carrying the infant astride one of her hips helps keep the legs apart and can help reduce muscle tightness. This position allows for better support and alignment, preventing further muscle contractures. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm would not provide the same benefits and may even exacerbate muscle tightness in a child with cerebral palsy.