Nokea
Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?
- A. Numbness, tingling, and cramps in the extremities.
- B. Headache, diaphoresis, and palpitations.
- C. Cyanosis, fever, and classic signs of shock.
- D. Nausea, vomiting, and muscular weakness.
Correct Answer: B
Rationale: Correct. Pheochromocytoma is a catecholamine-secreting non-cancerous tumor of the adrenal medulla. The classic triad of symptoms includes headache, diaphoresis (excessive sweating), and palpitations, which result from the overproduction of catecholamines like epinephrine and norepinephrine. Numbness, tingling, and cramps in the extremities (Option A) are not characteristic of pheochromocytoma. Cyanosis, fever, and classic signs of shock (Option C) are not typical symptoms of this condition. Nausea, vomiting, and muscular weakness (Option D) are not commonly associated with pheochromocytoma.
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In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's
- A. serum digoxin level is 1.5 ng/mL.
- B. blood pressure is 104/68 mmHg.
- C. serum potassium level is 3 mEq/L.
- D. apical pulse is 68/min.
Correct Answer: C
Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.
Which client should the nurse recognize as most likely to experience sleep apnea?
- A. Middle-aged female who takes a diuretic nightly.
- B. Obese older male client with a short, thick neck.
- C. Adolescent female with a history of tonsillectomy.
- D. School-aged male with a history of hyperactivity disorder.
Correct Answer: B
Rationale: The correct answer is B. Sleep apnea is characterized by pauses in breathing during sleep, often due to a collapsed or blocked airway. Obesity and having a short, thick neck are risk factors for sleep apnea because excess fat around the neck can obstruct the airway. Option A (middle-aged female who takes a diuretic nightly) does not present as a common risk factor for sleep apnea. Option C (adolescent female with a history of tonsillectomy) may have had tonsils removed, which could reduce the risk of sleep apnea. Option D (school-aged male with a history of hyperactivity disorder) is not directly associated with an increased risk of sleep apnea.
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
- A. Check it again in one month, and if it is still there schedule an appointment.
- B. Most lumps are benign, but it is always best to come in for an examination.
- C. Try not to worry too much about it, because usually, most lumps are benign.
- D. If you are in your menstrual period it is not a good time to check for lumps.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?
- A. Frequent urinary tract infections.
- B. Inability to get pregnant.
- C. Premenstrual syndrome.
- D. Chronic use of laxatives.
Correct Answer: B
Rationale: The correct answer is B: 'Inability to get pregnant.' The symptoms described in the client's complaints, which include severe abdominal pain before menstruation, painful intercourse, and painful defecation, are indicative of endometriosis. Endometriosis is a condition characterized by the abnormal presence of endometrial tissue outside the uterus, commonly leading to infertility. While choices A, C, and D may be associated with other conditions, they are not directly related to the symptoms described by the client, making them incorrect choices. Frequent urinary tract infections may suggest a different issue, premenstrual syndrome does not typically present with severe abdominal pain, and chronic use of laxatives is not a typical symptom of endometriosis.
The client is being taught about the best time to plan sexual intercourse in order to conceive. Which information should be provided?
- A. Two weeks before menstruation.
- B. Vaginal mucous discharge is thick.
- C. Low basal temperature.
- D. First thing in the morning.
Correct Answer: A
Rationale: The correct answer is A: 'Two weeks before menstruation.' Ovulation typically occurs 14 days before menstruation begins during a typical 28-day cycle. To increase the chances of conception, sexual intercourse should occur within 24 hours of ovulation. High estrogen levels during ovulation lead to changes in vaginal mucous discharge, making it more 'slippery' and stretchy. Basal temperature rises during ovulation. The timing of intercourse during the day is less significant than ensuring it happens around ovulation. The other options are incorrect because planning intercourse two weeks before menstruation is likely to miss the fertile window, thick vaginal mucous discharge indicates ovulation is approaching, and low basal temperature is not indicative of the fertile period.