Which of the following data regarding a client with a diagnosis of colon cancer are subjective?

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: D

Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: D

Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.

Correct Answer: B

Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.

Correct Answer: A

Rationale: Step 1: Vitamin B12 is absorbed in the small intestine with the help of intrinsic factor produced by parietal cells in the stomach. Step 2: Intrinsic factor binds to vitamin B12, forming a complex that is then absorbed in the ileum. Step 3: If intrinsic factor is lacking (as seen in pernicious anemia), vitamin B12 absorption is impaired, leading to megaloblastic anemia. Step 4: Administering cyanocobalamin bypasses the need for intrinsic factor. Step 5: Thus, intrinsic factor influences Vitamin B12 absorption. Other choices (B, C, D) do not play a direct role in Vitamin B12 absorption.

Correct Answer: D

Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache. Incorrect choices: A: To prevent confusion - Irrelevant to the procedure. C: To prevent seizures leakage - Seizures are not a concern with spinal blocks. D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.

Correct Answer: A

Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.