Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?

Correct Answer: C

Rationale: Most clients are not hospitalized long after a mastectomy. This is a key reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy. Typically, clients undergoing mastectomy have shorter hospital stays, often as part of the trend toward faster postoperative recovery and reduced healthcare costs. By ensuring that clients have appropriate home care arrangements and understand postoperative instructions early on, healthcare providers can support a smooth transition from the hospital to the home environment, promoting optimal recovery and outcomes for the client.

Correct Answer: C

Rationale: The disease mentioned in the question is likely myasthenia gravis. Myasthenia gravis is an autoimmune disorder where the body's immune system attacks acetylcholine receptors at the neuromuscular junction. Acetylcholine is a neurotransmitter responsible for transmitting nerve impulses to muscles. In myasthenia gravis, the immune system destroys or blocks the acetylcholine receptor sites on muscle cells, leading to a decrease in the number of functioning receptor sites. This results in muscle weakness and fatigue because the communication between nerves and muscles is impaired. This is why the nurse would base the reply on the knowledge that there is a decreased number of functioning acetyl-choline receptor sites as the underlying cause of the disease.

Correct Answer: D

Rationale: Autonomic dysfunction in TBI typically involves elevated temperature, heart rate, and respiratory rate due to dysregulation of the autonomic nervous system. Lowered blood pressure is less common and may indicate hypovolemia or other conditions rather than autonomic dysfunction.

Correct Answer: B

Rationale: An adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa is likely to exhibit tachycardia (rapid heart rate) and tachypnea (rapid breathing). These symptoms are common manifestations of the body's response to malnutrition and starvation. Tachycardia occurs as a compensatory mechanism to maintain an adequate supply of oxygen to vital organs, while tachypnea helps to eliminate excess carbon dioxide due to metabolic imbalances. It is essential for the nurse to recognize these signs during the physical assessment as they indicate the severity of the condition and the need for immediate intervention to prevent further complications. Dysmenorrhea and oliguria, heat intolerance and increased blood pressure, and lowered body temperature and brittle nails are not typically associated with the physical manifestations of anorexia nervosa.

Correct Answer: D

Rationale: Adalat (Procardia) belongs to a class of medications known as calcium channel blockers. Headache is a common side effect associated with the use of calcium channel blockers, including Adalat (Procardia). The mechanism behind this side effect is related to the vasodilatory effects of calcium channel blockers, which can lead to relaxation and widening of blood vessels, potentially causing headaches. It is important for the nurse to explain to the patient that headache is a possible side effect of Adalat (Procardia) and to consult the healthcare provider if it becomes bothersome or severe.

Correct Answer: A

Rationale: Acetabular dysplasia is the most common form of developmental dysplasia of the hip (DDH). It is characterized by an underdeveloped or shallow socket (acetabulum) in the hip joint, which can lead to instability and predispose the hip to dislocation. In DDH, the abnormal development of the hip joint can range from mild acetabular dysplasia to complete dislocation. Acetabular dysplasia is often present from birth or develops during infancy and can lead to long-term consequences if not properly managed. Early detection and treatment of acetabular dysplasia are crucial to prevent complications such as hip dislocation and osteoarthritis later in life.

Correct Answer: D

Rationale: The best response by the nurse in this scenario is option D: "It is a noninvasive test that uses magnetic energy to visualize internal parts." This response provides a clear and accurate description of what an MRI (Magnetic Resonance Imaging) involves. An MRI is a diagnostic test that uses a powerful magnetic field, radio waves, and a computer to create detailed images of the internal structures of the body. It is noninvasive, meaning there are no needles, electrodes, or injections involved. By explaining the procedure in a simple and understandable way, the nurse can help alleviate any anxiety or concerns the patient may have about the upcoming MRI.

Correct Answer: A

Rationale: Cretinism is a condition caused by congenital hypothyroidism. Common features of cretinism include umbilical hernia, wet skin, and feeding problems. Prolonged jaundice is not typically associated with cretinism. Jaundice is more commonly seen in conditions such as neonatal hepatitis or biliary atresia.

Correct Answer: A

Rationale: Pilocytic astrocytomas are generally low-grade and less responsive to chemotherapy compared to other listed tumors.