Question

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Answer 1

Correct Answers:

Apply a cold pack to the scrotal and penile areas.
Notify the healthcare provider immediately.

Rationale :

🧊Applying a cold pack to the scrotal and penile areas helps reduce localized swelling and inflammation, which is a common response following TURP and urinary tract instrumentation.

📞Notifying the healthcare provider immediately is appropriate because marked edema may indicate complications such as hematoma, infection, or impaired circulation, and requires prompt medical evaluation.

🛏️Placing a pillow under the buttocks may worsen venous congestion and is not a recommended intervention for genital edema, potentially increasing swelling.

🧪Obtaining a urinalysis is not relevant to external genital swelling unless there are signs of urinary tract infection, which are not described in this case.

🚫Removing the indwelling catheter is contraindicated without a specific provider order, as it may disrupt post-TURP healing and worsen urinary retention or bleeding.

📌Core Message

Post-TURP genital edema requires cold therapy to reduce swelling and prompt provider notification to rule out serious complications like hematoma or impaired circulation.

Answer 2

Correct Answers:

History of suicide attempts.

Rationale :

💉When a client reports current heroin use, a history of suicide attempts becomes the most critical factor in care planning because it greatly increases the risk of intentional or unintentional overdose, which may be fatal.

⚠️Heroin use is frequently associated with impulsivity, depressive symptoms, and hopelessness, all of which significantly heighten the danger of suicidal behaviors in those with a prior attempt history.

🧨While disorientation, social anxiety, or a family history of schizophrenia are clinically relevant, they do not present the same immediate threat to life as a suicide risk in the context of substance use.

🧠The priority in nursing care is always safety, and a combination of opioid use and suicidal history demands close monitoring, mental health evaluation, and potentially emergency intervention.

📌Core Message

In clients using heroin, a history of suicide attempts represents the most urgent risk, requiring focused safety planning and crisis-level intervention.

Answer 3

Correct Answers:

Brain damage with CP is not progressive but does have a variable course.

Rationale :

🧠Cerebral palsy (CP) results from a non-progressive brain injury that occurs during fetal development, birth, or infancy; this means the underlying brain damage does not worsen over time.

📈However, the course of CP can be variable, as symptoms like muscle stiffness, joint contractures, and functional limitations can change with growth and development, which sometimes gives the impression of worsening.

👣This distinction is crucial when teaching parents, as it clarifies that while the brain lesion remains stable, musculoskeletal complications or functional challenges may evolve and require ongoing intervention.

🎯Responses that focus only on habilitation, lesion development, or general prevalence (like the other choices) do not directly or accurately address the mother’s concern about progression of symptoms over time.

📌Core Message

Cerebral palsy involves a non-progressive brain injury, but the manifestations can change over time, making ongoing care and adaptive planning essential.

Answer 4

Correct Answers:

Withhold this dose.

Rationale :

⏱️If an infant vomits shortly after receiving digoxin, the nurse should instruct the parent to withhold the dose rather than repeat or alter it, as it is uncertain how much of the medication was absorbed.

💊Digoxin has a narrow therapeutic index, meaning even a small extra dose could lead to toxicity, especially in infants who are more vulnerable to adverse cardiac effects.

🚫Repeating the dose, giving a partial dose, or mixing with food (which may delay or alter absorption) are not safe practices unless explicitly directed by a healthcare provider after evaluation.

📞The best course is to hold the dose and notify the provider, who can then assess whether further dosing is needed based on timing, symptoms, and clinical status.

📌Core Message

When an infant vomits after receiving digoxin, the safest response is to withhold the dose and avoid risking toxicity due to uncertain absorption.

Answer 5

Correct Answers:

Teach the need for dietary and supplemental vitamin D.

Rationale :

🦴Clients with a history of extensive full-thickness burns are at risk for vitamin D deficiency due to impaired cutaneous synthesis from damaged skin, which can result in bone pain and muscle weakness over time.

☀️Although sunlight typically helps with vitamin D production, burned skin—especially with grafts or scarring—does not produce vitamin D effectively, making oral supplementation and dietary intake essential.

🥗Teaching about dietary and supplemental sources ensures the client can maintain adequate serum vitamin D levels, supporting bone mineralization and muscle function.

💪While muscle exercises and ROM are beneficial for physical rehabilitation, they do not address the root cause of the symptoms, which is likely nutritional and metabolic in origin.

📌Core Message

Clients with burn injuries involving large skin areas are prone to vitamin D deficiency, so dietary and supplemental education is key to managing bone and muscle complications.

Answer 6

Correct Answers:

Sedimentation rate
Anti-cyclic citrullinated peptide (anti-CCP) antibodies
C-reactive protein

Rationale :

🧪Sedimentation rate (ESR) is commonly elevated in rheumatoid arthritis (RA) due to ongoing systemic inflammation, making it a valuable marker in both diagnosis and monitoring.

🧬Anti-CCP antibodies are highly specific for RA and often appear early in the disease, even before radiologic joint damage, helping to confirm the diagnosis with greater precision than rheumatoid factor alone.

🔥C-reactive protein (CRP) is another sensitive acute phase reactant, and elevated levels reflect the intensity of inflammation in RA, aiding in both diagnosis and monitoring treatment response.

🧫D-Dimer is unrelated to autoimmune joint diseases and is typically used in evaluating thromboembolic conditions, not inflammatory arthritis.

🧬White blood cell count may fluctuate due to inflammation or medications but is not specific or primary in diagnosing or confirming RA.

📌Core Message

For suspected rheumatoid arthritis, the most important labs are those indicating inflammation (ESR, CRP) and autoimmune specificity (anti-CCP) to support accurate diagnosis.

Answer 7

Correct Answers:

Advise to have a case management evaluation of the client's home environment.

Rationale :

🏡A case management evaluation is the most appropriate first step because it provides a comprehensive assessment of the client's home environment, caregiving needs, and available community resources.

🧩This approach ensures the client receives personalized support planning, including referrals to home health, respite care, or rehabilitation services, based on her and her husband's medical and social needs.

🤝It also respects the client’s autonomy and current support system (e.g., her friend) while ensuring that all aspects of care coordination are addressed holistically through interdisciplinary input.

💬The other options contacting family, hiring a private nurse, or finding respite care—may eventually be part of the plan, but they are specific actions that should follow a professional evaluation, not precede it.

📌Core Message

A case management evaluation helps coordinate safe discharge planning and connect clients with the right care resources based on their unique home situation and caregiving demands.

Answer 8

Correct Answers:

Watery diarrhea.

Rationale :

💩Watery diarrhea in a client receiving linezolid may indicate the development of Clostridioides difficile (C. difficile)-associated diarrhea, a potentially serious adverse effect that must be reported immediately.

⚠️Linezolid is an oxazolidinone antibiotic that can disrupt normal gut flora, predisposing the client to C. difficile overgrowth, which can lead to severe colitis or toxic megacolon if untreated.

🦠Although symptoms like nausea and headache or yellow sputum may occur during infection treatment, they are not as immediately life-threatening as signs of antibiotic-associated colitis.

🛑Prompt recognition and reporting of C. difficile symptoms, such as profuse watery diarrhea, is critical to initiate timely diagnostic testing, isolate the client if needed, and prevent complications.

📌Core Message

Watery diarrhea may signal C. difficile infection, a serious complication of linezolid therapy that requires immediate medical attention.

Answer 9

Correct Answers:

Monitor daily sodium intake.

Rationale :

🧂SIADH causes dilutional hyponatremia due to excess water retention, making sodium imbalance a central and dangerous complication.

📉A sudden drop in serum sodium levels can result in neurological symptoms such as confusion, seizures, and even coma, so monitoring sodium intake helps prevent worsening hyponatremia.

📋Daily sodium intake monitoring supports both fluid management and helps guide therapeutic adjustments such as fluid restriction or sodium supplementation.

🔄Although diuretics may be used, they are typically implemented after careful evaluation, as they can worsen sodium loss; thus, monitoring and correcting sodium is the first and most critical step.

📌Core Message

In SIADH, managing hyponatremia by closely monitoring sodium intake is the most urgent priority to prevent neurological complications.

Answer 10

Correct Answers:

Elevated blood pressure must be anticipated and identified quickly.

Rationale :

🧠Acute glomerulonephritis leads to inflammation of the glomeruli, which causes sodium and fluid retention, increasing the risk of hypertension.

⚠️Elevated blood pressure is a common and serious complication of this condition and can lead to encephalopathy, seizures, or cardiac strain if not identified and managed promptly.

📈Frequent blood pressure monitoring allows for early detection and timely intervention to prevent life-threatening complications.

🗣️Explaining to the parents that anticipating and identifying hypertension is the reason for frequent checks provides an accurate and safety-focused rationale for the nursing action.

📌Core Message

In acute glomerulonephritis, frequent blood pressure monitoring is vital to anticipate and manage hypertension, preventing serious complications.

1 :
When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 :
During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 :
One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 :
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 :
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

1 : When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 : During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 : The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 : A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 : One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 : In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 : A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 : While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

1 :
When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 :
During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 :
One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 :
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 :
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?