The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?

Correct Answer: A

Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin. Incorrect choices: B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case. C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described. D: Hypocapnia - This is low carbon dioxide levels

Correct Answer: D

Rationale: The correct answer is D because being aware of patients' medication regimens allows nurses to identify and monitor ototoxic medications that can cause hearing loss. By collaborating with other professionals, nurses can adjust medications or recommend alternative treatments to prevent or minimize ototoxicity. This proactive approach directly targets the root cause of potential hearing loss. A: Understanding types of hearing loss is important but does not directly prevent ototoxicity. B: Educating about age-related changes in hearing does not address ototoxicity prevention. C: Educating about noise exposure risks is important for overall hearing health but does not specifically prevent ototoxicity.

Correct Answer: C

Rationale: The correct answer is C: anticonvulsant. Magnesium sulfate is used in the treatment of preeclampsia to prevent seizures, making it an anticonvulsant. It works by reducing neuromuscular excitability and stabilizing nerve cell membranes. Choice A (diuretic) is incorrect because magnesium sulfate does not primarily promote diuresis. Choice B (tocolytic) is incorrect as it does not inhibit uterine contractions. Choice D (antihypertensive) is incorrect because although magnesium sulfate can help lower blood pressure in preeclampsia, its primary indication in this case is for seizure prophylaxis.

Correct Answer: B

Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.

Correct Answer: B

Rationale: The correct answer is B: Contraction of bronchial smooth muscle. Histamine release can lead to bronchoconstriction, which narrows the airways and causes difficulty in breathing. This is a common symptom in allergic reactions like asthma. Constriction of small venules (Choice A) is not a typical consequence of histamine release. Dilation of large blood vessels (Choice C) is more associated with histamine's role in increasing vascular permeability. Decreased secretions from gastric and mucosal cells (Choice D) is not directly related to histamine's effects on smooth muscle contraction.

Correct Answer: A

Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.

Correct Answer: B

Rationale: The correct answer is B: Malignant cells contain proteins called tumor-specific antigens. Tumor-specific antigens are unique to cancer cells and are not found in normal cells. This characteristic distinguishes cancer cells from normal cells and is important in cancer detection and treatment. A: Malignant cells do not necessarily contain more fibronectin than normal body cells. Fibronectin is a glycoprotein found in the extracellular matrix and is not a defining characteristic of cancer cells. C: Chromosomes in cancer cells are actually more prone to instability and mutations compared to normal cells, making them less durable and stable. D: The nuclei of cancer cells can vary in size and shape, with irregularities often seen, rather than being unusually large and regularly shaped.

Correct Answer: C

Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.

Correct Answer: C

Rationale: The correct answer is C because it includes fiber-rich whole wheat bread, grapes, and walnuts which promote healthy bowel elimination. Whole wheat bread and fruits provide dietary fiber that aids in digestion and prevents constipation. Walnuts are high in omega-3 fatty acids which can also help with bowel regularity. Option A (Broccoli and cheese soup with potato bread) lacks fiber and may cause constipation due to the low fiber content. Option B (Turkey and mashed potatoes with brown gravy) may be low in fiber and high in fat, which can slow down digestion. Option D (Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing) is a healthier choice but may lack sufficient fiber for promoting healthy bowel elimination compared to option C.