Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?

Correct Answer: D

Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.

Correct Answer: D

Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.

Correct Answer: B

Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.

Correct Answer: C

Rationale: Rationale: 1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis. 2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas. 3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders. 4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies. 5. Therefore, the correct answer is C (Pituitary carcinoma). Summary: A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.

Correct Answer: B

Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client. A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia. C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment. D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.

Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.

Correct Answer: B

Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly. A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful. C: Opening the mouth wide while talking is not necessary and may be seen as patronizing. D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.

Correct Answer: C

Rationale: The correct answer is C: Hypercalcemia. In bone cancer, there can be excessive release of calcium from the bones, leading to elevated blood calcium levels. This can result in various complications such as kidney stones, cardiac arrhythmias, and weakness. Hyperkalemia (choice A) is not commonly associated with bone cancer. Hyponatremia (choice B) is more commonly seen in conditions like heart failure or kidney disease. Hypomagnesemia (choice D) is not a common electrolyte disturbance in bone cancer.

Correct Answer: D

Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.