BSN Hesi 266 Medical surg

The correct answer is C. Crohn's disease with colectomy.

Explanation:

Peritoneal dialysis (PD) is a form of dialysis that uses the peritoneum (the lining of the abdomen) as a filter to remove waste products and excess fluid from the body. For it to be successful, the peritoneal membrane must be intact and healthy. Crohn’s disease with colectomy: In this condition, the client has a history of inflammatory bowel disease (IBD), which can affect the bowel and the peritoneum. A colectomy (removal of the colon) may result in structural changes to the abdomen and peritoneal cavity, which can complicate the insertion and function of the peritoneal dialysis catheter, as well as increase the risk of infection or peritoneal membrane dysfunction. Therefore, this condition represents a contraindication for peritoneal dialysis.

Why the other options are incorrect:

a. Nephrotic syndrome history.

Nephrotic syndrome is a condition characterized by proteinuria, edema, and hypoalbuminemia, often caused by kidney diseases like glomerulonephritis. It does not directly contraindicate peritoneal dialysis. In fact, PD can be used in patients with nephrotic syndrome when renal function declines, as long as there are no other contraindications.

b. Latent hepatitis C.

Hepatitis C is a viral infection of the liver. Latent hepatitis C means that the virus is present but not currently active or causing symptoms. This condition does not typically interfere with the ability to undergo peritoneal dialysis. However, it’s important to monitor for liver function, and the patient may need antiviral therapy if the infection becomes active.

d. Type 2 diabetes mellitus.

Type 2 diabetes mellitus is a common condition among people with chronic kidney disease (CKD) and does not contraindicate peritoneal dialysis. In fact, people with diabetes can often undergo peritoneal dialysis, but they may require closer monitoring due to an increased risk of infections and other complications, such as peritoneal membrane dysfunction.

Summary:

Crohn’s disease with colectomy is a contraindication for peritoneal dialysis because the procedure requires a healthy and intact peritoneal membrane. The other conditions listed (nephrotic syndrome, latent hepatitis C, and type 2 diabetes) do not directly contraindicate the use of peritoneal dialysis.

Correct answer: B. Discuss perimenopause and related comfort measures.

Explanation:

Excessive sweating and feeling warm during the night, known as night sweats, are common symptoms during perimenopause, the transitional phase leading up to menopause. During this time, a woman’s hormone levels fluctuate, particularly the levels of estrogen and progesterone. These hormonal changes can cause hot flashes, which often occur at night and are followed by sweating, leading to night sweats. This is a normal part of the perimenopausal experience, and the nurse should provide education about this phase, as well as comfort measures to help manage the symptoms, such as wearing lightweight clothing, using fans, and avoiding triggers like hot beverages or spicy foods.

Why the other options are wrong:

A. Explain the effect of the follicle-stimulating and luteinizing hormones:

While follicle-stimulating hormone (FSH) and luteinizing hormone (LH) do play roles in menopause, this answer is less directly related to the client's symptoms. The client’s complaint of night sweats is more related to hormonal changes as a whole rather than just the effects of FSH and LH. Providing information about the broader topic of perimenopause would be more relevant and helpful.

C. Assess lung fields and for a cough productive of blood-tinged mucus:

This response is more relevant to concerns about respiratory or infectious diseases, such as tuberculosis or pneumonia. While night sweats can be a symptom of certain infections, the client’s description points more to a hormonal cause, not an infectious one. This option would not be the most appropriate response in this case.

D. Ask if a fever above 101 F (38.3 C) has occurred in the last 24 hours:

A fever of this degree is more indicative of an infection or a systemic illness rather than perimenopausal symptoms. Since the client did not mention any fever or other signs of illness, it would be premature to ask about a fever without first addressing the more likely cause of night sweats, which is hormonal changes related to perimenopause.

Summary:

The best response to the client’s concern about excessive sweating and warmth at night is to discuss perimenopause and the hormonal changes that accompany it. This phase can cause hot flashes and night sweats, and the nurse can offer helpful strategies to manage these symptoms. The other responses, while addressing potential causes like infection, are less relevant to the client’s description of the symptoms.

The correct answer is B. Calcium loss from bones can be slowed by increasing calcium intake and exercise.

Explanation:

Osteoporosis is a condition that involves the weakening of bones, making them more susceptible to fractures. The risk of developing osteoporosis increases after menopause due to the decrease in estrogen levels, which can contribute to bone loss. Although genetic factors (such as having a family history of osteoporosis) play a role, lifestyle modifications can significantly help in managing and preventing the condition. Increasing calcium intake and engaging in weight-bearing exercises, such as walking or resistance training, can help slow down bone loss. These measures are essential for maintaining bone density and reducing the risk of fractures.

Why the Other Options Are Incorrect:

A. Osteoporosis is a progressive genetic disease with no effective treatment: While genetics can influence the risk of developing osteoporosis, the condition is not without effective treatments. In addition to lifestyle changes (e.g., calcium intake, exercise), there are several medications available to treat osteoporosis and slow down bone loss, such as bisphosphonates and selective estrogen receptor modulators (SERMs). So, the idea that there is no effective treatment is inaccurate.

C. Estrogen replacement therapy should be started to prevent the progression of osteoporosis: Estrogen replacement therapy (ERT) was historically used to treat and prevent osteoporosis in postmenopausal women. However, due to concerns about potential risks (e.g., breast cancer, heart disease), ERT is no longer the first-line treatment. It is typically used in specific cases under close medical supervision, and lifestyle modifications (calcium, exercise) are usually preferred as initial interventions for prevention.

D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis: Corticosteroids, while used to treat a variety of conditions, can actually increase the risk of osteoporosis when used long-term. They can lead to a decrease in bone density. Therefore, using corticosteroids as a treatment to halt osteoporosis is not appropriate. In fact, patients on long-term corticosteroid therapy are often monitored for signs of bone loss and may be prescribed other treatments to prevent osteoporosis.

Summary:

The best advice for the client concerned about osteoporosis is to emphasize the importance of increasing calcium intake and engaging in regular weight-bearing exercise, as these are the most effective strategies to slow calcium loss from bones and maintain bone health. While genetic factors do play a role, lifestyle changes can significantly mitigate the risk of osteoporosis and its complications.

The correct answer is: d. Teach the client techniques for performing intermittent catheterization.

Explanation:

Urinary retention in multiple sclerosis (MS) occurs due to impaired communication between the brain and the bladder, leading to difficulty initiating or fully emptying the bladder. Since the retention is related to sensorimotor dysfunction, the most effective approach to managing it involves helping the client maintain bladder function through regular emptying of the bladder.

Teach the client techniques for performing intermittent catheterization:

Intermittent catheterization is an effective method for managing urinary retention in individuals with MS. This technique allows the client to empty their bladder regularly, reducing the risk of urinary tract infections (UTIs) and preventing complications from prolonged urinary retention, such as kidney damage. The nurse should teach the client how to perform intermittent catheterization and provide guidance on the proper technique, hygiene, and frequency to ensure the bladder is emptied fully and effectively.

Why the other options are incorrect:

a. Remind the client to practice pelvic floor (Kegel) exercises regularly:

Pelvic floor exercises (Kegel exercises) can be helpful for individuals with some forms of urinary incontinence, but they are generally not effective for urinary retention, especially when it is related to neurological causes such as MS. In cases of urinary retention, the primary issue is the inability to fully empty the bladder, which Kegel exercises do not address.

b. Provide a bedside commode for immediate use in the client's discomfort:

While a bedside commode may offer convenience for the client, it does not address the root cause of urinary retention. The client may still be unable to empty the bladder properly, and providing a commode will not help with the management of retention itself. The focus should be on techniques for managing urinary retention, such as intermittent catheterization.

c. Explain the need to limit intake of oral fluids to reduce client discomfort:

Limiting fluid intake is not a recommended strategy for managing urinary retention in clients with MS. In fact, inadequate hydration can lead to concentrated urine, which may irritate the bladder and increase the risk of urinary tract infections. Encouraging proper hydration is important, and the key to managing discomfort and retention is through techniques that help the client empty the bladder properly, such as intermittent catheterization.

Summary

For a client with urinary retention due to multiple sclerosis, the most appropriate action is to teach the client techniques for performing intermittent catheterization. This approach directly addresses the inability to fully empty the bladder and helps prevent complications such as UTIs and kidney damage. The other options are either not directly effective for urinary retention or do not address the primary issue.

The correct answer is: C. Maintain a fluid intake of 3 to 4 L per day.

Explanation:

Multiple myeloma is a type of cancer that affects plasma cells in the bone marrow, leading to a variety of complications such as bone damage, renal failure, and immune suppression. One of the most critical interventions in preventing complications in clients with multiple myeloma is maintaining proper hydration, specifically aiming for a fluid intake of 3 to 4 liters per day. This is essential because multiple myeloma can lead to hypercalcemia, where elevated calcium levels in the blood can cause kidney damage and stones. Adequate hydration helps prevent renal complications by aiding in the excretion of calcium and preventing dehydration, which can exacerbate kidney problems.

Why the other options are wrong:

A. Safety precautions during activity. While safety precautions during activity are important, they are not the most critical intervention for preventing complications in a client with multiple myeloma. The priority in this condition is addressing the risk of kidney damage from hypercalcemia and ensuring proper fluid balance. However, safety is still important to address bone fragility due to the bone lesions that are characteristic of multiple myeloma.

B. Assess for changes in size of lymph nodes. Lymph node enlargement is not a typical or primary complication of multiple myeloma. This condition primarily affects the bone marrow, leading to bone pain, fractures, and kidney problems, rather than lymphadenopathy. Therefore, assessing for changes in lymph node size is less of a priority in preventing complications compared to managing fluid intake and kidney function.

D. Administer narcotic analgesic around the clock. Pain management is essential for clients with multiple myeloma due to bone pain from lytic lesions or fractures, but administering narcotic analgesics around the clock is not the most important intervention to prevent complications. Managing kidney function through fluid intake is a higher priority to prevent renal failure. Pain management should be adjusted based on the client’s specific needs and condition but is secondary to hydration in preventing complications.

Summary:

The most important intervention to include in the care plan for a client with multiple myeloma is to maintain a fluid intake of 3 to 4 liters per day. This is vital for preventing complications such as kidney damage and hypercalcemia. Although other interventions, like safety precautions, pain management, and lymph node assessment, are important, hydration is the primary concern for preventing renal issues in these clients.

The correct answer is A. Low back pain and hypotension.

Explanation:

An AOB (acute organ injury due to blood transfusion) incompatibility reaction typically occurs due to a mismatch in blood types during a transfusion. The body’s immune system recognizes the transfused blood as foreign and mounts an immune response, which can lead to hemolysis (destruction of red blood cells). Symptoms of this reaction can be severe and include low back pain, hypotension, fever, chills, and dark urine (due to hemoglobin released from destroyed red blood cells). The presence of low back pain and hypotension indicates that the client may be experiencing an acute hemolytic transfusion reaction, which is a medical emergency and requires immediate intervention to prevent further complications such as kidney damage and shock.

Why the other options are wrong:

B. Rhinitis and nasal stuffiness

Rhinitis and nasal stuffiness are not indicative of an acute hemolytic transfusion reaction. These symptoms are more likely associated with an allergic response or upper respiratory issues, which are not typically linked to AOB incompatibility. Rhinitis is usually a mild condition and does not require the same level of immediate intervention as the severe symptoms of hemolytic reactions.

C. Delayed painful rash with urticarial

A delayed painful rash with urticaria (hives) is a more common sign of a mild allergic reaction to blood transfusion, such as urticaria or allergic transfusion reactions. While this may cause discomfort and require some intervention (e.g., antihistamines), it is not as urgent or life-threatening as low back pain and hypotension, which suggest acute hemolytic reaction.

D. Arthritic joint changes and chronic pain

Arthritic joint changes and chronic pain are not associated with an acute transfusion reaction. These symptoms may indicate a long-term autoimmune condition, such as rheumatoid arthritis, or another chronic illness, but they are unrelated to blood transfusion reactions. In this context, they are not urgent findings related to transfusion-related complications.

Summary:

The most immediate finding to report after a blood transfusion, in the context of AOB incompatibility, is low back pain and hypotension. These symptoms are indicative of a potential acute hemolytic transfusion reaction, which is a medical emergency that requires immediate intervention to prevent serious complications such as kidney failure or shock.

Correct Answer: C. Purulent sputum.

Explanation 

The most concerning finding in this case is purulent sputum. Corticosteroids, even when used short-term for conditions like allergies, can suppress the immune system and increase the client's risk for infections, particularly respiratory infections such as pneumonia or bronchitis. Purulent sputum indicates the presence of infection and could suggest the development of a bacterial respiratory infection. Given that the client is on corticosteroids, this increases the importance of promptly assessing and addressing any potential infections.

Why the Other Options Are Incorrect:

A. White blood count of 10,000 mm³.

A white blood cell (WBC) count of 10,000/mm³ is within the normal range (typically 4,000–11,000/mm³). Although corticosteroids can cause mild elevations in WBC counts due to demargination of neutrophils, this level is not concerning in itself. It does not suggest an active infection unless there is a significant increase or other signs of infection present.

B. Serum glucose of 115 mg/dl.

A serum glucose of 115 mg/dl is slightly elevated but generally still within a mild range. Corticosteroids can elevate blood glucose levels, especially with prolonged use, but a serum glucose level of 115 mg/dl is not immediately alarming. Persistent hyperglycemia over time would require attention, but this level alone is not likely a cause for concern in the short term.

D. Excessive hunger.

Excessive hunger, or polyphagia, is a known side effect of corticosteroid therapy, especially with long-term use. While this may be an uncomfortable side effect, it is not as concerning as a potential infection. The nurse should still monitor the client’s diet and manage any weight gain or metabolic changes, but this side effect alone is not an urgent issue.

Summary:

The most concerning finding in a client taking oral corticosteroids is the presence of purulent sputum, which may indicate a respiratory infection. Corticosteroids can suppress the immune system, increasing the risk of infection, so it is critical to assess for signs of infection like purulent sputum. The other findings, such as a normal WBC count, mildly elevated blood glucose, and excessive hunger, are more common side effects of corticosteroids and are not as immediately concerning

Correct Answer: B. Headache, diaphoresis, and palpitations.

Explanation 

Pheochromocytoma is a rare tumor of the adrenal medulla that leads to excessive secretion of catecholamines, primarily epinephrine and norepinephrine. This results in episodic hypertension, which manifests with the classic triad of symptoms: headache, diaphoresis (excessive sweating), and palpitations. These symptoms occur due to excessive sympathetic nervous system stimulation, leading to increased heart rate, vasoconstriction, and excessive sweating.

Why the Other Options Are Incorrect:

A. Numbness, tingling, and cramps in the extremities.

These symptoms are more commonly associated with electrolyte imbalances, such as hypocalcemia (low calcium levels), hypokalemia (low potassium levels), or neuropathy rather than pheochromocytoma. Pheochromocytoma primarily affects the cardiovascular system and autonomic nervous system rather than causing peripheral nerve symptoms.

C. Cyanosis, fever, and classic signs of shock.

Cyanosis and shock suggest a severe circulatory failure, such as sepsis or cardiogenic shock, which is not characteristic of pheochromocytoma. Although pheochromocytoma can cause extreme hypertension and, in severe cases, lead to cardiovascular collapse, the typical early symptoms involve hypertension rather than shock-related findings like cyanosis.

D. Nausea, vomiting, and muscular weakness.

While nausea and vomiting can occasionally occur in pheochromocytoma due to excessive catecholamine release, they are not the primary or most characteristic symptoms. Muscular weakness is more commonly seen in conditions such as hypokalemia, myasthenia gravis, or neuromuscular disorders.

Summary:

Pheochromocytoma is a tumor that causes excessive catecholamine secretion, leading to episodes of severe hypertension. The classic triad of symptoms is headache, diaphoresis, and palpitations, which occur due to the overstimulation of the sympathetic nervous system. The other options describe symptoms related to electrolyte imbalances, shock, or neuromuscular disorders, which are not characteristic of pheochromocytoma. Prompt recognition of these symptoms is critical for early diagnosis and treatment.

The correct answer is A. K.

Explanation:

Cholestyramine (Questran) is a bile acid sequestrant used to lower cholesterol levels in individuals with hyperlipidemia. It works by binding to bile acids in the intestine, which are then excreted in the stool. Since bile acids are necessary for the absorption of fat-soluble vitamins (A, D, E, and K), cholestyramine can interfere with the absorption of these vitamins. Vitamin K is a fat-soluble vitamin, and its deficiency can lead to issues with blood clotting, as vitamin K is essential for the synthesis of clotting factors. Cholestyramine can cause vitamin K deficiency by reducing its absorption.

Why the Other Options Are Incorrect:

B. B12: Vitamin B12 is a water-soluble vitamin, and its absorption is not significantly affected by cholestyramine. B12 absorption occurs in the ileum, and cholestyramine mainly affects the absorption of fat-soluble vitamins

C. B6: Vitamin B6, like B12, is water-soluble and not significantly impacted by cholestyramine.

D. C: Vitamin C is also a water-soluble vitamin, so its absorption is not affected by cholestyramine.

Summary:

​​​​​​​When a client is receiving cholestyramine for hyperlipidemia, they should be evaluated for vitamin K deficiency due to the drug’s potential to impair the absorption of fat-soluble vitamins.