This medical-surgical nursing question is related to cerebrovascular, colostomy, celiac disease, glomerulonephritis, cerebral injury, craniotomy, lithotripsy, glucose level, ketoacidosis, and increased intracranial pressure.
Here are the Following Question Of Medical-Surgical Nursing
After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has a left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?
|a. checking stools for occult blood|
|b. performing range-of-motion exercises to the left side|
|c. keeping skin clean and dry|
|d. elevating the head of the bed to 30 degrees|
D is the correct answer. Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pinholes in the drainage bag to help relieve gas. The nurse should teach him that this action
|a. destroys the odor-proof seal|
|b. won’t affect the colostomy system|
|c. is appropriate for relieving the gas in a colostomy system|
|d. destroys the moisture barrier seal|
A is the correct answer. Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.
When assessing the client with celiac disease, the nurse can expect to find which of the following?
|b. jaundiced sclerae|
|c. clay-colored stools|
|d. widened pulse pressure|
A is the correct answer. Because celiac disease destroys the absorbing surface of the intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclera results from elevated bilirubin levels. Clay-colored stools are seen with the biliary disease when bile flow is blocked. Celiac disease doesn’t cause widened pulse pressure.
A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because
|a. reducing sodium promotes urea nitrogen excretion|
|b. reducing sodium improves her glomerular filtration rate|
|c. reducing sodium increases potassium absorption|
|d. reducing sodium decreases edema|
D is the correct answer. Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn’t affected by sodium intake.
The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the
|a. frontal lobe|
|b. parietal lobe|
|c. occipital lobe|
|d. temporal lobe|
D is the correct answer. The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.
The nurse is assessing a post craniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect
|a. Cushing’s syndrome|
|b. Diabetes mellitus|
|c. Adrenal crisis|
|d. Diabetes insipidus|
D is the correct answer. Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is under secretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
The nurse is providing post-procedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to
|a. limit oral fluid intake for 1 to 2 weeks|
|b. report the presence of fine, sandlike particles through the nephrostomy tube.|
|c. Notify the physician about cloudy or foul-smelling urine|
|d. Report bright pink urine within 24 hours after the procedure|
C is the correct answer. The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal because of residual stone products. Hematuria is common after lithotripsy.
A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority
|a. deficient fluid volume related to osmotic diuresis|
|b. decreased cardiac output related to elevated heart rate|
|c. imbalanced nutrition: Less than body requirements related to insulin deficiency|
|d. ineffective thermoregulation related to dehydration|
A is the correct answer. A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition: Less than body requirements isn’t appropriate. A temperature of 100.6º F isn’t life-threatening, eliminating ineffective thermoregulation as the top priority.
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s
|a. onset to be at 2 p.m. and its peak at 3 p.m.|
|b. onset to be at 2:15 p.m. and its peak at 3 p.m.|
|c. onset to be at 2:30 p.m. and its peak at 4 p.m|
|d. onset to be at 4 p.m. and its peak at 6 p.m|
C is the correct answer. Regular insulin, which is short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 pm.
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHg and the ICP is18 mmHg; therefore his cerebral perfusion pressure CPP is
|a. 52 mm Hg|
|b. 88 mm Hg|
|c. 48 mm Hg|
|d. 68 mm Hg|
A is the correct answer. CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequatecerebral perfusion to take place, the minimumgoal is 70 mmHg. The MAP is derived using the following formula:MAP = ((diastolic blood pressure x 2) + systolicblood pressure) / 3MAP = ((60 x2) + 90) / 3MAP = 70 mmHgTo find the CPP, subtract the client’s ICP fromthe MAP; in this case , 70 mmHg – 18 mmHg =52 mmHg.