Nokea
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: The correct answer is not provided in the choices. However, if I were to choose from the given options, the most appropriate would be C: "Because they are prone to reduced renal efficiency." This is important because older adults may have decreased kidney function, leading to potential complications with IV therapy. Option A is incorrect as defense mechanisms are not directly related to monitoring IV therapy. Option B is incorrect as fluid overload is a general concern with IV therapy regardless of age. Option D is irrelevant to the need for monitoring IV therapy in older adults.
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The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication of hypophysectomy, the surgical removal of the pituitary gland. The pituitary gland plays a crucial role in regulating water balance in the body, and its removal can lead to excessive urine production. Choices A, B, and C are incorrect because a decrease in stress does not typically cause polyuria, diabetes mellitus is not an immediate complication of surgery, and polyuria is not an expected result of pituitary gland removal.
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?
- A. Intrinsic factor
- B. Histamine
- C. Hydrochloric acid
- D. Liver enzyme
Correct Answer: A
Rationale: Step 1: Vitamin B12 is absorbed in the small intestine with the help of intrinsic factor produced by parietal cells in the stomach.
Step 2: Intrinsic factor binds to vitamin B12, forming a complex that is then absorbed in the ileum.
Step 3: If intrinsic factor is lacking (as seen in pernicious anemia), vitamin B12 absorption is impaired, leading to megaloblastic anemia.
Step 4: Administering cyanocobalamin bypasses the need for intrinsic factor.
Step 5: Thus, intrinsic factor influences Vitamin B12 absorption. Other choices (B, C, D) do not play a direct role in Vitamin B12 absorption.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
- A. Diabetic ketoacidosis
- B. Hypoglycemia
- C. Thyroid crisis
- D. Tetany
Correct Answer: C
Rationale: The correct answer is C: Thyroid crisis. These signs suggest thyroid storm, a life-threatening complication of thyroid surgery. The high fever, tachycardia, and restlessness are classic symptoms. Thyroid crisis can lead to severe complications if not managed promptly.
A: Diabetic ketoacidosis typically presents with polyuria, polydipsia, and fruity breath odor.
B: Hypoglycemia would present with symptoms like diaphoresis, tremors, and confusion.
D: Tetany is associated with hypocalcemia and presents with muscle cramps, spasms, and numbness.
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.