BSN Hesi 266 Medical surg

The correct answer is: A. Sodium.

Explanation:

Primary hyperaldosteronism, also known as Conn's syndrome, is characterized by the overproduction of aldosterone, a hormone produced by the adrenal glands. Aldosterone plays a key role in regulating sodium and potassium balance. It acts on the kidneys to increase sodium reabsorption and promote potassium excretion. In primary hyperaldosteronism:

Increased sodium levels: Aldosterone causes increased sodium reabsorption in the kidneys, leading to higher sodium levels in the blood (hypernatremia).

Decreased potassium levels: Excess aldosterone leads to increased potassium excretion, which often results in hypokalemia (low potassium levels).

Decreased renin levels: In primary hyperaldosteronism, the excessive aldosterone secretion suppresses renin production.

Why the other options are incorrect:

B. Antidiuretic hormone: Aldosterone's action is independent of antidiuretic hormone (ADH), which regulates water balance. While both affect fluid balance, ADH is not the primary factor involved in primary hyperaldosteronism.

C. Potassium: In primary hyperaldosteronism, potassium levels typically decrease due to increased renal excretion. Therefore, potassium would likely be low, not increased.

D. Glucose: Glucose levels are not typically elevated in primary hyperaldosteronism. Hyperaldosteronism primarily affects electrolyte balance, particularly sodium and potassium, rather than glucose metabolism.

Summary:

In primary hyperaldosteronism, sodium levels are typically increased due to the excessive action of aldosterone promoting sodium retention in the kidneys.

The correct answer is: a. anxiety and sighing

Explanation:

Episodes of weakness and palpitations in a client with type 2 diabetes mellitus may be related to hypoglycemia, which is a potential complication of diabetes, especially if the client is on medications like insulin or sulfonylureas. Anxiety and sighing are common symptoms that can occur when blood glucose levels drop too low. Hypoglycemia can lead to adrenergic responses such as sweating, palpitations, trembling, and feelings of anxiety. In some cases, individuals may sigh as a physiological response to feeling anxious or short of breath during a hypoglycemic episode.

Why the other options are incorrect:

b. Myalgia in wrists and hands:

Myalgia (muscle pain) is not typically associated with hypoglycemia or the early stages of diabetes complications. This could be related to other conditions, but it is not a direct sign of hypoglycemia or an immediate complication of diabetes.

c. Hyperactive bowel sounds:

Hyperactive bowel sounds are generally not related to diabetes mellitus or hypoglycemia. This could be indicative of gastrointestinal disturbances or other conditions, but it does not point toward a common complication of diabetes.

d. Dark yellow urine:

Dark yellow urine could be indicative of dehydration or concentrated urine but is not a typical sign of hypoglycemia. It could be due to insufficient fluid intake or other causes, but it is not immediately suggestive of a diabetic complication related to the symptoms of weakness and palpitations.

Summary

The nurse should recognize anxiety and sighing as a possible sign of hypoglycemia, a common complication for clients with type 2 diabetes mellitus. This condition can result in weakness, palpitations, and a range of physiological responses, including anxiety. Other options, such as myalgia, hyperactive bowel sounds, and dark yellow urine, are not typically associated with hypoglycemia or diabetes complications.

Correct Answer: C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity.

Explanation 

Thrombophlebitis is inflammation of a vein due to a blood clot and often occurs in the deep veins of the legs (deep vein thrombosis, DVT). Classic symptoms of DVT include:

Calf pain (especially with movement or exertion).

Redness, warmth, and swelling in the affected area.

Pain relief when the leg is elevated (because elevation helps reduce venous pressure and swelling).

Pain upon exertion that is relieved by rest and elevation is consistent with venous thrombosis rather than arterial insufficiency or muscular pain.

Explanation of Incorrect Answers:

A. Pain in the calf awakening him from a sound sleep.

Nocturnal leg pain is more characteristic of muscle cramps (such as nocturnal leg cramps or restless leg syndrome) rather than thrombophlebitis or DVT.

B. Calf pain on exertion which stops when standing in one place.

This is more characteristic of intermittent claudication, which occurs due to arterial insufficiency (peripheral artery disease, PAD). DVT pain does not improve simply by standing still—it is typically worsened by movement.

D. Pain upon arising in the morning which is relieved after some stretching and exercise.

Morning stiffness that improves with movement is more typical of musculoskeletal conditions like arthritis or muscle tightness rather than venous thrombosis.

Summary:

Thrombophlebitis (DVT) is most strongly associated with calf pain that worsens with exertion and improves with rest and leg elevation.

The correct answer is:A. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).

Explanation:

Intrauterine devices (IUDs) are a highly effective form of contraception but do not protect against sexually transmitted diseases (STDs). For individuals with multiple sexual partners, there is an increased risk of exposure to STDs, which can lead to pelvic inflammatory disease (PID). PID can increase the risk of infertility, ectopic pregnancy, and other complications. Therefore, it is important for sexually active individuals with multiple partners to be aware that an IUD does not offer protection against STDs.

Why the other options are less appropriate:

B. Getting pregnant while using an IUD is common and is not the best contraceptive choice: This statement is incorrect. An IUD is actually highly effective in preventing pregnancy. The risk of pregnancy with an IUD is very low, especially when it is properly inserted and monitored.

C. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission: While this statement is true in that barrier methods (such as condoms) are more effective in preventing STDs, it does not fully address the risk of PID in sexually active individuals with multiple partners. It's important to note that an IUD does not protect against STDs, so a barrier method is still recommended in combination for STD protection.

D. Selecting a contraceptive device should consider choosing a successful method used in the past: While past contraceptive methods are an important consideration in selecting a contraceptive device, this option does not address the key concern about STD prevention, which is particularly relevant in the case of multiple sexual partners.

Summary:

The nurse should provide information to the client that the IUD does not protect against STDs, which increases the risk of pelvic inflammatory disease. Barrier methods (such as condoms) should be used to prevent the transmission of STDs.

The correct answer is D. Inflammatory with peau d'orange.

Explanation:

Inflammatory breast cancer with peau d'orange (a condition where the skin of the breast appears dimpled and resembles the peel of an orange) is a rare and aggressive form of breast cancer that tends to have a poor prognosis. This type of cancer typically presents with symptoms such as rapid breast swelling, redness, pain, and skin changes that can occur within a short period of time. Inflammatory breast cancer is often diagnosed at an advanced stage and can spread more quickly, which contributes to its poorer prognosis.

Why the Other Options Are Incorrect:

A. Stage II: Stage II breast cancer refers to tumors that are generally larger than in stage I but still localized to the breast or nearby lymph nodes. While stage II cancer is more advanced than stage I, it is not the most advanced or aggressive stage, and its prognosis is not as poor as that of inflammatory breast cancer.

B. Invasive infiltrating ductal carcinoma: This is the most common type of breast cancer, but it does not inherently have the poorest prognosis. The prognosis depends on the tumor's size, lymph node involvement, and metastasis. Invasive infiltrating ductal carcinoma can range in severity, and its prognosis can be relatively good if detected early and treated properly.

C. T1N0M0: This refers to a tumor classification used in the TNM staging system. T1 indicates a small tumor (usually 2 cm or smaller), N0 indicates no regional lymph node involvement, and M0 indicates no metastasis. This classification suggests an early-stage, localized tumor and would typically have a better prognosis compared to more advanced stages of cancer or inflammatory breast cancer.

Summary:

Inflammatory breast cancer with peau d'orange has the poorest prognosis among the options listed. It is an aggressive and fast-growing form of breast cancer that typically has a worse outcome due to its rapid spread and difficulty in early detection.

The correct answer is: D. If the client's wound is infected.

Explanation:

A Penrose drain is a soft, flexible, rubber drain used to remove fluid from a wound or surgical site. It's important to know if the wound is infected because an infected wound can pose a risk to other patients, especially if the drainage is contaminated.

Room selection depends on infection control. If the client has an infected wound, the nurse may need to place the client in a private room to prevent the spread of infection to other patients.

If the wound is infected, this would guide decisions such as the need for isolation precautions (e.g., contact precautions) and ensuring the room has appropriate equipment and infection control measures in place.

Why the other options are less critical:

A. If suctioning will be needed for drainage of the wound: While suctioning may be required in some cases, it is not the most important factor when choosing a room. The infection status of the wound takes precedence to ensure safe isolation and proper infection control.

B. If the family would prefer a private or semi-private room: While family preferences are important for patient satisfaction, the infection status is a higher priority for safety, particularly in terms of preventing the spread of infection.

C. null: This option is not relevant

Summary:

The most important information to obtain is whether the client's wound is infected to ensure appropriate infection control measures are in place and to determine whether the client requires a private room to reduce the risk of transmission to other patients.

The correct answer is: D. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.

Explanation:

Modified Chest Lead One (MCL I) telemetry monitoring is designed to simulate the Lead I of a standard 12-lead ECG. It is primarily used to monitor atrial rhythms and help distinguish between ventricular and supraventricular rhythms. In this configuration, the placement of electrodes follows these key steps:

Positive electrode (red) is placed at the right chest nipple line (typically in the 4th intercostal space at the midclavicular line).

Negative electrode (white) is placed at the left shoulder.

The ground electrode (green) is placed at the left chest nipple line (similarly around the 4th intercostal space, midclavicular line).

This positioning ensures the correct orientation of the lead and gives accurate readings for atrial rhythms and other heart functions during telemetry monitoring.

Why the other options are wrong:

A. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. This configuration is incorrect because the positive electrode should not be on the right shoulder, and the negative electrode should not be placed on the left shoulder. The correct placement for MCL I requires the positive electrode on the right chest nipple line and the negative electrode on the left shoulder, with the ground electrode placed on the left chest nipple line.

B. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. This option places the positive electrode on the left shoulder, which is incorrect for MCL I. The positive electrode should be on the right chest nipple line, not the left shoulder. The negative electrode's placement is also swapped with the ground electrode here, which is inaccurate.

C. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. The placement of the negative electrode on the left chest nipple line is incorrect. In MCL I configuration, the negative electrode should be positioned on the left shoulder, not on the chest. The ground electrode should remain at the left chest nipple line.

Summary:

The correct electrode placement for MCL I telemetry monitoring is:

Positive electrode on the right chest nipple line (4th intercostal space, midclavicular line),

Negative electrode on the left shoulder,

Ground electrode on the left chest nipple line (4th intercostal space, midclavicular line).

This configuration allows for accurate monitoring of atrial rhythms and differentiates between ventricular and supraventricular rhythms.

The correct answer is  C. Eat a high-fiber diet and increase fluid intake.

Explanation:

Diverticulosis is a condition in which small pouches (diverticula) form in the colon. The goal of dietary recommendations for clients with diverticulosis is to prevent complications, such as diverticulitis (inflammation or infection of the diverticula). A high-fiber diet is recommended because fiber helps promote regular bowel movements and reduces the risk of constipation, which can lead to increased pressure in the colon and exacerbate the condition. Increased fluid intake is also important to help fiber pass through the intestines more easily, which can further help prevent constipation and discomfort.

Why the other options are wrong:

A. Have small frequent meals and sit up for at least two hours after meals.

This instruction is not related to managing diverticulosis. While eating small frequent meals may help some people with conditions such as gastroesophageal reflux disease (GERD), it is not a key recommendation for managing diverticulosis. The focus for diverticulosis should be on increasing fiber intake and ensuring adequate hydration.

B. Eat a bland diet and avoid spicy foods.

A bland diet and avoiding spicy foods are typically recommended for conditions like gastritis or peptic ulcers, but not for diverticulosis. In fact, avoiding certain foods such as high-fat or processed foods is important in diverticulosis, but there is no specific need to eat a bland diet or avoid spicy foods unless they trigger symptoms.

D. Eat a soft diet with increased intake of milk and milk products.

A soft diet may be recommended during flare-ups of diverticulosis (e.g., in cases of diverticulitis), but it is not a general recommendation for the long-term management of diverticulosis. Additionally, increasing milk and milk products is not part of the standard dietary guidance for diverticulosis, as some people with this condition may also have lactose intolerance or may experience discomfort from dairy products. The focus should be on increasing fiber and fluid intake.

Summary:

For a client diagnosed with diverticulosis, the most important dietary recommendation is to eat a high-fiber diet and increase fluid intake to prevent constipation and reduce the risk of complications. This is the best strategy to help manage the condition effectively.

Correct answer: A. Move into airborne isolation

Explanation:

The client is presenting with symptoms commonly associated with tuberculosis (TB), including intermittent fever, night sweats, a productive cough with blood, and a prolonged duration of symptoms. Since tuberculosis is an airborne disease, the highest priority is to prevent the potential spread of the infection to others. Placing the client in airborne isolation ensures that any airborne pathogens, like the bacteria causing TB, are contained within the room and do not spread to other individuals. This isolation includes using an N95 respirator for healthcare providers and ensuring the patient wears a surgical mask if they need to leave the room.

Why the other options are wrong:

B. Arrange transport for radiographic imaging:

While radiographic imaging, such as a chest X-ray, may be necessary to diagnose conditions like tuberculosis, the priority intervention is isolation to prevent the spread of potential infection. Radiographic imaging should be done after the client is safely placed in isolation.

C. Collect specimens for blood cultures:

While blood cultures may be important for diagnosing systemic infections, the client’s primary symptoms are indicative of a respiratory infection, likely tuberculosis. The priority is to manage airborne precautions and collect sputum samples to confirm TB, rather than focusing immediately on blood cultures.

D. Obtain a sputum sample:

Obtaining a sputum sample is indeed important to confirm a diagnosis of tuberculosis, but it should not be the first action. Airborne isolation must be established first to ensure that the client’s potential infectious status does not put others at risk.

Summary:

The priority intervention is to place the client in airborne isolation to prevent the spread of a possible airborne infection such as tuberculosis. This action is crucial for infection control, especially in the early stages of diagnosis, while other diagnostic measures, such as sputum sampling and radiographic imaging, are still being arranged.