Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?

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Question 1 of 5

Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?

Correct Answer: A

Rationale: The correct answer is A: Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Electrolyte imbalances can lead to neurological complications, so accurate monitoring is essential. Mini-mental status and Glasgow Coma scale are assessments of mental status, not electrolyte balance. Vital signs can provide some information, but intake and output measurement is more specific for assessing electrolyte imbalances and dehydration.

Question 2 of 5

Which of the ff. statements would the nurse understand is true when assessing normal auditory acuity using the Rinne test?

Correct Answer: B

Rationale: The correct answer is B because in a normal Rinne test, air conduction is heard longer than bone conduction in both ears. This is due to the fact that air conduction involves the transmission of sound waves through the external auditory canal, middle ear, and inner ear, which is more efficient than bone conduction where the sound waves are transmitted directly to the inner ear through the bones of the skull. Therefore, when the tuning fork is placed on the mastoid bone (bone conduction) and then moved next to the ear (air conduction), the sound should be heard longer through air conduction. Choice A is incorrect because normal auditory acuity does not necessarily mean equal perception in both ears. Choice C is incorrect as bone conduction should be heard shorter than air conduction in a normal Rinne test. Choice D is incorrect as the test does not determine which ear perceives sound better, but rather the difference in duration between air and bone conduction.

Question 3 of 5

Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?

Correct Answer: C

Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms. Avoiding noises (A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (D) may help with pain but will not address the underlying cause of vertigo. Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.

Question 4 of 5

When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?

Correct Answer: C

Rationale: The correct answer is C: Restricting sodium. In hyperparathyroidism, there is an excess of parathyroid hormone leading to increased calcium levels. Sodium can worsen calcium excretion, exacerbating the condition. Restricting sodium can help reduce calcium loss. A: Restricting fluids is not necessary unless the client has kidney issues. B: Forcing fluids may not be beneficial and can lead to fluid overload. D: Restricting potassium is not typically necessary unless the client has kidney issues.

Question 5 of 5

When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?

Correct Answer: C

Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.

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