The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Correct Answer: C

Rationale: Objective data are measurable and observable, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.

Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. Sigmoidoscopy is a direct visualization procedure that allows for examination of the lower part of the colon and rectum, where colorectal cancer commonly occurs. This procedure can help identify any abnormal growths or polyps that may indicate cancer. Stool hematest (A) detects blood in stool but does not confirm colorectal cancer. Abdominal CT (B) provides imaging of the abdomen but may not definitively diagnose colorectal cancer. CEA scan (C) measures a tumor marker associated with colorectal cancer but is not a definitive diagnostic test. Thus, sigmoidoscopy is the most appropriate diagnostic study for confirming colorectal cancer.

Correct Answer: D

Rationale: The correct answer is D: menstrual flow. In a 28-year-old female with Cushing syndrome, excess cortisol levels can disrupt the menstrual cycle, leading to irregular or absent periods. Successful treatment for Cushing syndrome aims to restore normal cortisol levels, which should result in the resumption of regular menstrual flow. This indicates that the hormonal balance is improving. Now, let's analyze the other choices: A: Serum glucose level - While Cushing syndrome can lead to hyperglycemia, successful treatment would aim to normalize glucose levels, not cause a decline. B: Bone mineralization - Cushing syndrome can cause osteoporosis due to loss of bone density, but successful treatment would help prevent further bone loss rather than decline. C: Hair loss - Cushing syndrome can cause hair loss, but successful treatment would not necessarily lead to a decline in hair loss as it may take time for hair to regrow. Therefore, the correct answer is D as it directly relates to the restoration of hormonal

Correct Answer: C

Rationale: The correct answer is C: Generalized seizure. This type of seizure involves both hemispheres of the brain from the onset, leading to loss of consciousness and tonic-clonic jerking. It is characterized by widespread, synchronized electrical discharges. A: Focal seizures start in one area of the brain, leading to localized symptoms without loss of consciousness. B: Jacksonian seizures are a type of focal seizure characterized by a progression of jerking movements from one body part to another. D: Partial seizures involve only one part of the brain, leading to localized symptoms or altered consciousness without loss of awareness.

Correct Answer: B

Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions. A: Abnormal distribution of body hair is not directly related to hypophysectomy. C: While fluid intake may be important post-surgery, it is not the primary focus of teaching. D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues. In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.

Correct Answer: C

Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice D) are less likely to be monitored together as they are not commonly seen in the same clinical context.

Correct Answer: A

Rationale: The correct answer is A: Inspecting for bleeding or cyanosis. During uterosigmoidostomy, the nurse's critical task is to monitor for any signs of bleeding or cyanosis, which are indicators of potential complications such as hemorrhage or impaired blood flow. This involves observing the surgical site for any abnormal bleeding and assessing the skin color for signs of inadequate oxygenation. Inspecting for symptoms of peritonitis (B) is not directly related to this surgical procedure. Assessing the client's allergy to iodine (C) is important but not a critical task during the procedure. Checking for signs of electrolyte losses (D) is important but not as critical as monitoring for immediate postoperative complications like bleeding or cyanosis.

Correct Answer: C

Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.

Correct Answer: B

Rationale: The correct answer is B because right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.