A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require
__
as evidenced by the client’s
_
and
____
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}

The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.

Rationale:

(i)

B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.

(ii)

C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.

F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.

Incorrect:

(i)

A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss

C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.

D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.

E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.

(ii)

A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.

B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.

D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.

E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.

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Correct Answer is A

Explanation

A) Temporary memory loss: Temporary memory loss is a well-known and common side effect following electroconvulsive therapy (ECT). Clients may experience short-term memory issues, such as forgetting events that occurred around the time of the procedure or difficulties recalling information. This side effect is usually temporary and tends to resolve as the brain recovers from the procedure.

B) Voice alteration: Voice alteration is not a typical side effect of electroconvulsive therapy. ECT primarily affects brain function, particularly memory and cognitive processes, and does not have a direct effect on the voice or vocal cords.

C) Tingling of the scalp: Tingling of the scalp is not a common adverse reaction to
electroconvulsive therapy. While there may be some minor physical sensations or discomfort during the procedure, tingling is not a typical side effect associated with ECT.

D) Neck pain: Neck pain is not a usual adverse reaction of electroconvulsive therapy. Some discomfort might occur after the procedure due to muscle tension or the positioning during the therapy, but it is not a common or prominent side effect like memory loss.

A. "Wash the site daily with warm water B. "Wash skin markings off after each treatment. C. "Apply lotion to the site after treatment." D. "Cover the site with a transparent dressing

Correct Answer is A

Explanation

A) "Wash the site daily with warm water": The nurse should instruct the client to wash the radiation treatment site gently with warm water and mild soap (without scrubbing or using harsh soaps). This helps to cleanse the skin without irritating it. Keeping the skin clean can help prevent infection and minimize irritation during the course of radiation therapy. It's important not to use hot water or harsh chemicals, as the skin in the treated area can be sensitive.

B) "Wash skin markings off after each treatment": Skin markings are placed on the client's skin by the radiation oncologist to ensure the radiation is targeted precisely. These marks should not be washed off, as they are necessary for the planning and delivery of radiation. Washing off the marks could affect the accuracy of the treatment.

C) "Apply lotion to the site after treatment": While it may seem like a good idea to apply lotion to moisturize the skin, clients undergoing radiation therapy should avoid applying any lotions, creams, or ointments to the radiation site unless specifically prescribed by their healthcare provider. Some lotions or creams may contain chemicals that could irritate the skin further or interfere with the radiation treatment. Only approved products should be used.

D) "Cover the site with a transparent dressing": Covering the radiation treatment site with a transparent dressing is typically not recommended unless the client has an open wound or is instructed to do so by the healthcare provider. The treated skin should be left exposed to air to promote healing unless advised otherwise. Covering the site could trap moisture, leading to skin irritation or infection.

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A nurse is assisting with the care of a client who is admitted to the medical surgical unit. Complete the following sentences by using the list of options: The nurse anticipates the client will likely require ______ as evidenced by the client’s _______ and ______.

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A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require
__
as evidenced by the client’s
_
and
____
.