Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?

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: In the scenario of an elderly patient like Mr. Cruz with suspected pulmonary embolism, the nurse would anticipate an order for the immediate administration of heparin. Heparin is an anticoagulant medication that works quickly to prevent the further development of blood clots. It is often used as the initial treatment for pulmonary embolism to prevent existing blood clots from getting larger and reduce the risk of new clots forming. Heparin is preferred over warfarin initially because it has a more rapid onset of action. Warfarin, which is a commonly used anticoagulant for longer-term management, takes several days to reach its full effect and requires monitoring of the prothrombin time (INR). Therefore, in Mr. Cruz's acute situation, heparin would be the most appropriate choice for immediate intervention to address the pulmonary embolism.

Correct Answer: C

Rationale: Romberg's test is a neurological test that assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception and vibration sensations. A lumbar injury can affect these dorsal columns, leading to impaired proprioception. Therefore, the Romberg's test would be affected due to the compromised sensory input from the lower extremities. This test usually involves asking the patient to stand with feet together and eyes closed to assess balance and proprioception.

Correct Answer: B

Rationale: Raynaud's disease is a condition characterized by vasospasms of the small arteries, usually in the fingers and toes, in response to cold temperatures or stress. Smoking can worsen the symptoms of Raynaud's disease because it causes vasoconstriction, which is the narrowing of blood vessels. Nicotine in cigarettes can trigger vasospasms, leading to further restriction of blood flow to the extremities. Therefore, it is essential for individuals with Raynaud's disease to stop smoking to help improve blood circulation and reduce the frequency and severity of vasospasms.

Correct Answer: B

Rationale: Coercion should not be involved in obtaining informed consent as it undermines the voluntary nature of the decision-making process. Informed consent should be freely given by the patient without any form of pressure or manipulation. The other criteria for valid informed consent that a nurse should identify include that it is freely given, includes an explanation of procedures, and describes the alternatives available to the patient.