Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?

Correct Answer: D

Rationale: The correct answer is D: pain in the scapular region. This is because a herniated nucleus pulposus at the C4-C5 and C5-C6 interspaces typically results in pain radiating from the neck to the scapular region due to nerve compression at those levels. The other choices are incorrect as constant, throbbing headaches are not typically associated with this specific diagnosis, clonus in the lower extremities is more indicative of lower spinal cord involvement, and numbness of the face is not a common symptom of herniated discs at these levels.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. This involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia. The nurse should monitor for this sign in clients at risk for low calcium levels. Hypoglycemia and hypokalemia have specific signs and symptoms not related to Trousseau's sign. Respiratory changes are nonspecific and may not be directly related to monitoring for low calcium levels.

Correct Answer: C

Rationale: The correct answer is C: Fat. Excessive ingestion of fat has been linked to autoimmunity due to its potential to trigger inflammation in the body, which can disrupt the immune system's balance and lead to autoimmune responses. High-fat diets have been associated with increased production of pro-inflammatory molecules, impacting immune function negatively. Protein (choice A) is essential for immune function, vitamin A (choice B) supports immune responses, and zinc (choice D) is crucial for immune system regulation. However, excessive intake of these nutrients typically does not directly lead to autoimmunity like excessive fat consumption does.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: C

Rationale: The correct answer is C: Hemoptysis. In the later stages of TB, the infection can lead to damage in the lungs, causing blood to be coughed up (hemoptysis). This is a serious symptom indicating advanced disease progression. Fatigue (A), anorexia (B), and weight loss (D) are common symptoms of TB but can occur in earlier stages as well. Hemoptysis specifically indicates more severe lung involvement, making it characteristic of later stages.

Correct Answer: B

Rationale: The correct answer is B because a client's medical history of allergy to iodine or seafood is crucial for urinary diversion assessment to prevent potential adverse reactions during procedures involving contrast media or seafood-based medications. It is essential to ensure the client's safety and avoid any allergic reactions. Choice A is incorrect because assessing sexual function is not directly related to urinary diversion assessment. Choice C is also incorrect as urinary diversion does not typically affect nervous control. Choice D is irrelevant to the assessment of a client undergoing urinary diversion.

Correct Answer: B

Rationale: Step 1: The scenario describes Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children. Step 2: Choice B is correct because it recognizes Toni's behavior as a coping mechanism to deal with her illness. Step 3: Minimizing visual problems and focusing on future goals can be a way for Toni to maintain a positive outlook and cope with her challenges. Step 4: Choices A, C, and D are incorrect because they do not address Toni's behavior as a coping mechanism. Choice A mentions euphoria, which is not supported by the scenario. Choice C and D do not acknowledge Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.