Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?

Correct Answer: B

Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention. A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry. C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation. D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.

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: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.

Correct Answer: D

Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is a hallmark feature of Huntington's disease, caused by damage to the basal ganglia. Intellectual decline includes cognitive impairments such as memory loss and executive dysfunction. Emotional disturbances involve mood swings, irritability, and apathy. Therefore, all three manifestations are commonly seen in individuals with Huntington's disease, making D the correct choice. Choices A, B, and C are incorrect individually because they do not encompass all the key clinical features of Huntington's disease.

Correct Answer: A

Rationale: The correct answer is A: Anemia. Anemia is a common condition characterized by a decrease in red blood cells or hemoglobin levels, leading to symptoms like fatigue and weakness. It is often suspected based on symptoms such as pale skin and shortness of breath. Rheumatic arthritis (B) is a type of arthritis affecting joints, not related to the blood. Leukemia (C) is a type of cancer affecting the blood and bone marrow. Systemic Lupus Erythematosus (SLE) (D) is an autoimmune disease that can affect various organs, not specifically related to blood cell levels. Therefore, based on the symptoms described, anemia is the most likely condition to be suspected.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production. 2. High corticotropin levels would be expected due to the adenoma's overproduction. 3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands. 4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer. Summary: - Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma. - Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma. - Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.

Correct Answer: B

Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures. Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.

Correct Answer: C

Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.

Correct Answer: A

Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.