A female client recovers from a serious case of insect bites. What skin related advice must the nurse give to the client and all her family members to prevent the recurrence of the ailment?

Correct Answer: B

Rationale: The nurse should advise the client and her family members to apply insect repellent to clothing and exposed skin to prevent insect bites in the future. Insect repellents containing DEET, picaridin, or oil of lemon eucalyptus are effective in repelling mosquitoes, ticks, and other insects that may cause bites. By regularly applying insect repellent, they can reduce the risk of getting bitten and prevent a recurrence of the ailment. Other preventive measures such as wearing long sleeves and pants, avoiding heavily wooded or grassy areas, and using screens on windows and doors can also be beneficial in preventing insect bites.

Correct Answer: B

Rationale: In the Rinne test, a tuning fork is placed first on the mastoid bone behind the ear to test bone conduction, and then beside the ear to test air conduction. A normal finding in the Rinne test is when air conduction (heard beside the ear) is longer than bone conduction (heard on the mastoid bone) in both ears. This indicates that sound waves travel through the air better than through bone. If air conduction is heard longer than bone conduction, it suggests normal auditory acuity.

Correct Answer: D

Rationale: In the syndrome of inappropriate antidiuretic hormone (SIADH), there is an excessive release of antidiuretic hormone (ADH), leading to water retention by the kidneys and dilution of electrolytes in the blood. This can result in hyponatremia and fluid overload. Therefore, the appropriate nursing intervention for a client with SIADH is to restrict fluids to help prevent further fluid retention and worsening of hyponatremia. Infusing IV fluids rapidly, administering glucose-containing IV fluids, or encouraging increased oral fluid intake would exacerbate the problem by further diluting the electrolyte concentration in the blood. By restricting fluids, the aim is to maintain a strict intake and output balance to promote a gradual increase in serum sodium levels and help restore normal fluid balance in the body.

Correct Answer: A

Rationale: Following a unilateral adrenalectomy, there is a risk of developing hyperkalemia due to the altered balance of electrolytes. Hyperkalemia is characterized by high levels of potassium in the blood, which can lead to various symptoms. One of the key manifestations of hyperkalemia is muscle weakness. This occurs because high potassium levels can disrupt the normal function of skeletal muscles, leading to weakness and potentially affecting motor function. Therefore, the nurse would assess for muscle weakness as a sign of hyperkalemia in a patient following a unilateral adrenalectomy. Options B, C, and D are not typically associated with hyperkalemia.

Correct Answer: B

Rationale: After a right lower lobectomy, it is important to keep the patient in a semi-Fowler's position to promote lung expansion and oxygenation. This position helps to reduce pressure on the diaphragm and allows for better lung ventilation. By maintaining the patient in a semi-Fowler's position, it can help prevent complications such as atelectasis and pneumonia postoperatively. It is a crucial nursing intervention to ensure optimal respiratory function and promote recovery after lung surgery.