Medical Surgical Exam 4 (NSG 123)

The correct answer is  B: I am so glad that I will never have another seizure.

Explanation for the correct answer:

B I am so glad that I will never have another seizure:

This statement indicates a need for further teaching. Vagal nerve stimulation (VNS) does not cure epilepsy or guarantee that seizures will never occur again. It is an adjunct therapy used to reduce the frequency, severity, and duration of seizures in individuals who do not respond adequately to medication. Clients need to understand that while VNS can help control seizures, it is not a definitive cure.

Why the other options are incorrect:

A. My doctor can change the settings as needed:

This is correct. The settings of a VNS device can be adjusted by the healthcare provider using a special programming device to optimize effectiveness and minimize side effects.

C. This device will send electrical signals to my brain:

This is correct. Although the VNS device stimulates the vagus nerve, the stimulation affects brain activity, particularly in areas involved in seizure activity. So, the client is essentially correct in saying it sends signals that influence brain function.

D. I know a potential complication is a cough or throat spasm:

This is correct. A common side effect of VNS, especially when stimulation occurs, is hoarseness, throat discomfort, cough, or throat spasms. This shows appropriate understanding of expected complications.

Summary:

The client statement that suggests they believe they will “never have another seizure” reflects a misunderstanding of the purpose of VNS. It does not eliminate seizures entirely but helps reduce their occurrence. The other statements reflect accurate understanding of the device’s function, adjustability, and possible side effects.

The correct answer is A: I will need to have a mammogram every 2 yrs beginning at 45

Explanation for the correct answer:

A. I will need to have a mammogram every 2 yrs beginning at 45

The current guidelines recommend that women begin mammography screening for breast cancer at age 45, with the option to begin at age 40 if they wish. Mammograms should be done every year until age 54, and after that, they can be done every 2 years. This recommendation is based on research showing that regular mammograms help detect breast cancer early, improving outcomes for women.

Why the other options are wrong:

B. I should have colonoscopy every 15 yrs beginning at 60

This is incorrect. The American Cancer Society recommends that individuals begin colorectal cancer screening at age 45. The typical guidelines suggest that colonoscopies should be done every 10 years, not every 15 years, for individuals at average risk of colorectal cancer. Screening can be done more frequently depending on risk factors or findings during previous screenings.

C. I will need to have an annual breast exam every year after 40

This is incorrect. While breast self-exams and clinical breast exams can be part of early detection, the American Cancer Society no longer recommends routine clinical breast exams for women at average risk. The focus for women over 40 is on regular mammograms, rather than annual clinical breast exams.

D. I should have a fecal occult test done every 3 years

This is incorrect. The recommended frequency for fecal occult blood testing (FOBT) for colorectal cancer screening is annually, not every 3 years. It is one of the options for screening, but it should be done every year, or individuals may choose other screening options, like colonoscopies every 10 years.

Summary:

The statement that indicates an understanding of cancer screening prevention is A, where the client correctly identifies that mammograms should begin at age 45 and be done every 2 years. Other options either misunderstand the frequency or age of screening for other types of cancer.

The correct answer is D: Aura

Explanation for the correct answer:

D. Aura

The presence of light flashes (also called visual disturbances) is a typical symptom of the aura phase of a migraine. This phase occurs before the headache begins and is characterized by sensory disturbances, such as visual changes (e.g., flashing lights, zigzag lines), tingling sensations, or numbness. These symptoms usually last from a few minutes to about 30 minutes.

Why the other options are incorrect:

A. Postdrome

The postdrome phase occurs after the headache subsides. It is sometimes called the "migraine hangover" phase, where the person may feel fatigued, confused, or "washed out." Visual disturbances like light flashes are not associated with this phase.

B. Premonitory

The premonitory phase (also called the prodrome phase) happens 24-48 hours before the migraine headache starts. It involves general symptoms such as mood changes, food cravings, neck stiffness, or fatigue, but it does not typically include visual disturbances like light flashes.

C. Headache

The headache phase of a migraine is characterized by severe, throbbing pain, usually on one side of the head. This phase is not typically associated with visual disturbances such as light flashes, although light sensitivity (photophobia) can occur.

Summary:

The light flashes described by the client are part of the aura phase of a migraine, which precedes the headache and is often accompanied by other sensory disturbances.

The correct answer is D: grunting

Explanation for the correct answer:

Grunting is a significant and concerning finding in an infant with respiratory distress. It is a compensatory mechanism used by infants to increase airway pressure and keep the alveoli open during expiration. Grunting typically occurs when an infant is struggling to breathe effectively, and it indicates that the infant is experiencing severe respiratory distress. This sign often suggests that the infant's oxygenation is compromised, and immediate intervention is necessary to prevent further deterioration.

Why the other options are wrong:

A. Tachypnea

Tachypnea (rapid breathing) is a common early sign of respiratory distress in infants, but it is less concerning than grunting. It can be seen in various conditions such as fever, infection, or mild respiratory distress, and while it may require monitoring, it is not as immediately alarming as grunting, which suggests severe distress.

B. Mild retractions

Mild retractions (the inward movement of the skin around the ribs or sternum during breathing) can indicate respiratory distress, but mild retractions are usually not as serious as more severe retractions (e.g., suprasternal, intercostal, or subcostal retractions). Mild retractions should still be monitored, but they are less of a priority than grunting in terms of urgency.

C. Wheezing

Wheezing can be an important finding in respiratory distress, particularly in conditions like asthma or bronchiolitis, but it is usually associated with obstructive rather than restrictive lung conditions. While wheezing can be concerning, grunting is more immediately indicative of severe respiratory compromise, particularly in newborns or infants.

Summary:

Grunting (D) is the most concerning sign in an infant with respiratory distress as it indicates severe respiratory effort and potential hypoxia. While tachypnea, mild retractions, and wheezing are all signs of respiratory distress, they are generally less urgent than grunting, which signals the need for immediate medical intervention to address the infant’s respiratory needs.

The correct answer is C: provide oral care with disposable mouth swab

Explanation for the correct answer:

C. provide oral care with disposable mouth swab

Mucositis is an inflammation of the mucous membranes, often a result of chemotherapy or radiation therapy. It can cause painful sores and make oral hygiene difficult. Using a disposable mouth swab is a gentle way to clean the oral cavity without irritating the lesions or causing further discomfort. It helps maintain oral hygiene and reduces the risk of infection, which is particularly important for immunocompromised patients.

Why the other options are wrong:

A. administer biological response modifier

Biological response modifiers (such as growth factors or immunotherapy) can help stimulate the immune system or promote healing in certain cases, but they are not the primary treatment for mucositis. The goal for mucositis is symptom management and maintaining oral hygiene, not modifying the immune response through these medications.

B. encourage oral care with commercial mouthwash

Commercial mouthwashes, especially those containing alcohol or strong flavors, can irritate the mucosal lining and worsen mucositis symptoms. Mouthwashes specifically designed for mucositis are recommended, but general commercial mouthwash may not be beneficial and could be harmful for clients with painful oral lesions.

D. maintaining NPO until lesions have resolved

While it may be difficult for the client to eat due to pain, maintaining the client NPO (nothing by mouth) until the lesions resolve is not an ideal approach. Nutritional intake is important, and the client should be encouraged to take small, soft meals or liquids that are gentle on the mouth, such as bland or non-acidic foods. Enteral feeding or appropriate substitutes should be considered for nutrition if oral intake becomes too painful or insufficient.

Summary:

Option C (providing oral care with a disposable mouth swab) is the best intervention as it helps maintain oral hygiene gently and minimizes irritation to mucosal lesions, which is crucial for clients with mucositis. Other options do not directly address the management of mucositis symptoms effectively.

The correct answer is D: The older a woman gets, the greater chance of developing breast cancer.

Explanation for the correct answer:

D. The older a woman gets, the greater chance of developing breast cancer.

As women age, the risk of developing breast cancer increases, especially after the age of 50. This is due to factors such as longer exposure to estrogen and the accumulation of genetic mutations over time. Age is one of the most significant risk factors for breast cancer, with most cases being diagnosed in women aged 50 and older. This makes it a key focus when educating senior women on the importance of breast health and regular screenings.

Why the other options are wrong:

A. Clients should find out about their family history of breast cancer.

While family history is an important risk factor, this is more relevant for younger women or those with a strong family history of breast cancer. However, even without a family history, the risk of breast cancer increases with age, so while this is useful information, age-related risk is the most important factor to emphasize to senior women.

B. Men at this age can get breast cancer also and should be screened.

While breast cancer in men is possible, it is rare. The risk of breast cancer in men is much lower than in women, and this is not the most important concern for a class of senior women. The focus should be on the risks specific to women, especially those related to age.

C. Monthly breast self-exams is the key to early detection.

Breast self-exams (BSE) have been de-emphasized in recent years, as research has shown they do not significantly reduce mortality from breast cancer. Regular mammograms and clinical breast exams are more effective for early detection. Emphasizing self-exams over other methods could be misleading.

Summary:

The most important risk factor for breast cancer in older women is age. As women age, especially after 50, the risk of developing breast cancer increases. While other factors, such as family history and self-exams, are important, age-related risk should be the primary focus in education for senior women. Regular screenings, such as mammograms, are essential for early detection and improved outcomes.

The correct answer is B: The client is taking a prescribed oral contraceptive.

Explanation for the correct answer:

Oral contraceptives can significantly impact thyroid function tests. They are known to increase the level of thyroid-binding globulin (TBG), a protein that binds to thyroid hormones (such as T4 and T3). This increase in TBG results in elevated total T4 and T3 levels in the blood, which can interfere with the interpretation of thyroid hormone levels. Therefore, the use of oral contraceptives can affect thyroid diagnostic test results, particularly in measurements of total thyroid hormone levels, and should be considered when interpreting the test.

Why the other options are incorrect:

A: A diagnosis of schizophrenia:

Schizophrenia itself does not directly affect thyroid function tests. Although schizophrenia may be treated with medications that can influence thyroid function (such as antipsychotics), the condition itself does not impact the results of thyroid diagnostic tests. Therefore, schizophrenia would not significantly alter thyroid function test outcomes.

C: The client takes vitamin C daily:

Vitamin C is a common supplement, and while it has various health benefits, it does not interfere with thyroid hormone levels or thyroid diagnostic tests. There is no clinical evidence suggesting that daily vitamin C intake would affect thyroid function testing.

D: A history of obesity:

While obesity can sometimes be associated with thyroid dysfunction (such as hypothyroidism), it does not directly impact the accuracy of thyroid diagnostic tests. Obesity alone would not alter thyroid hormone levels or interfere with the results of a thyroid function test.

Summary:

The use of oral contraceptives can increase thyroid-binding globulin (TBG) levels, which in turn can affect the accuracy of thyroid hormone measurements, particularly for total T4 and T3 levels. This makes oral contraceptives a key factor to consider when interpreting thyroid diagnostic tests. The other options, such as schizophrenia, vitamin C use, and obesity, do not have a direct effect on thyroid function tests, making them less relevant in this context.

The correct answers are

B. fruity odor of breath,

C.abd pain

D.Kussmaul respirations,

E.metabolic acidosis

Explanation for the correct answers:

B: Fruity odor of breath

Fruity odor of breath is characteristic of diabetic ketoacidosis (DKA) due to the presence of acetone, a type of ketone body produced during the breakdown of fats in the body when glucose is not available for energy. This odor is a hallmark sign of ketosis and DKA.

C: Abdominal pain

Abdominal pain is a common symptom of DKA. It can be caused by the acidosis and the metabolic disturbances that occur during DKA. Abdominal pain can also occur due to dehydration and electrolyte imbalances often present in DKA.

D: Kussmaul respirations

Kussmaul respirations, which are deep, labored breathing, are a compensatory mechanism seen in DKA. They occur as the body tries to expel carbon dioxide to compensate for metabolic acidosis (the buildup of hydrogen ions), which is one of the key features of DKA.

E: Metabolic acidosis

Metabolic acidosis is a fundamental feature of DKA. It occurs due to the accumulation of ketone bodies (acids) in the blood, which results from the breakdown of fats when there is insufficient insulin to allow cells to use glucose for energy.

Why A: Weight gain is incorrect:

A: Weight gain

Weight gain is not typically associated with DKA. In fact, DKA usually causes weight loss due to the loss of fluids, electrolytes, and muscle mass from dehydration and the breakdown of fat and muscle for energy. Therefore, weight gain is not expected in this condition.

Summary:

In DKA, the nurse should expect to find a fruity odor of breath, abdominal pain, Kussmaul respirations, and metabolic acidosis. Weight gain is not a typical finding in DKA, as the condition usually leads to dehydration and weight loss.

The correct answer is C: Rapidly administer IV infusion of 0.9% sodium chloride.

Explanation for the correct answer:

C: Rapidly administer IV infusion of 0.9% sodium chloride

Diabetic ketoacidosis (DKA) is characterized by severe dehydration due to high blood glucose levels and osmotic diuresis. One of the first steps in treating DKA is to replenish fluid volume with an IV infusion of normal saline (0.9% sodium chloride). The initial infusion is typically given rapidly to correct dehydration and improve circulation. Normal saline is the preferred solution for rehydration, as it helps to restore intravascular volume without affecting blood sugar levels.

Why the other options are incorrect:

A: Admin IV infusion of regular insulin at 0.3 unit/kg/hr

While insulin is an essential part of DKA treatment, the initial dose of insulin typically begins at 0.1 unit/kg/hr as a continuous IV infusion after the fluid resuscitation is started. The prescribed rate of 0.3 unit/kg/hr is too high for the initial stage of treatment. The purpose of insulin is to lower blood glucose and reverse ketosis, but it should not be given too rapidly at the beginning due to the risk of causing hypoglycemia or rapid shifts in electrolytes.

B: Admin slow IV infusion of 3% sodium chloride

3% sodium chloride (hypertonic saline) is used in cases of severe hyponatremia (low sodium levels), not in the treatment of DKA. For DKA, normal saline (0.9% sodium chloride) is used for initial fluid replacement, and only if hyponatremia is present, or there is an indication of cerebral edema, would hypertonic saline be considered.

D: Add glucose to the IV infusion when blood glucose is 350

In DKA, the glucose level should not be lowered too quickly. Initially, glucose should be reduced at a steady pace with insulin therapy. Glucose is added to the IV infusion when blood glucose reaches around 200-250 mg/dL to prevent hypoglycemia. Adding glucose too early (at 350 mg/dL) can result in unnecessary complications, as the main goal in the early stages is to correct hyperglycemia and ketosis.

Summary:

In the treatment of DKA, the priority is fluid resuscitation using 0.9% sodium chloride (normal saline). After fluid volume is corrected, insulin therapy is then started at a lower rate (0.1 unit/kg/hr) to reduce blood glucose. The administration of hypertonic saline (3% sodium chloride) or adding glucose to the infusion at inappropriate times is not part of the initial management.