2023 NURSING PRACTICE 4 - CARE OF CLIENTS WITH PHYSIOLOGICAL
ANDPSYCHOSOCIAL ALTERATIONS Q&A SUCCESS ASSUARED
While doing admission history and assessment, the client asks the nurse if parathyroid and thyroid glands
are the same. The correct response of the nurse is:
A. The thyroid glands regulate metabolism while the parathyroid glands regulate calcium and phosphates.
B. The thyroid glands secrete iodine while the parathyroid glands secrete calcium and magnesium.
C. Both are located in the dorsal area of the neck responsible for regulating breathing and voice
respectively.
D. Both glands are secreting hormones that regulate body processes.
Answer. A. Reference: 1253, Brunner
During the history taking, Loreli states that she is taking Furosemide (Lasix). You understand that the
indication of the medication is to:
A. Lower sodium level C. Increase renal clearance of
B. Interfere with calcium resorption calcium
D. Lower calcium level
Answer. D. Loop diuretics such as your Lasix, decrease sodium, potassium. The loss of Magnesium and Calcium is
equivalent to that of your sodium. This drug is also used in emergency cases of hypercalcemia. (431, Bennett Clinical
Pharmacology, 10th Ed.)
Loreli was put on low calcium diet to decrease the total intake of calcium and prevent renal calculi.
You will instruct the client to avoid which of the following foods?
A. Oats, potatoes, soybean C. Rice, malunggay leaves and carrots
B. Oranges, yogurts, spinach D. Whole grain, leafy vegetables, milk
Answer. D. Though all choices contain foods rich in calcium, letter D, which contains milk and leafy vegetables are
rich sources of calcium thus is chosen as the answer.
The doctor orders: “Monitor for signs of renal stones.” What is the most appropriate nursing intervention to
accomplish such doctor’s order?
A. Visually examine urine every after urination C. Use glass container when measuring urine
B. Observe color of urine every after urination output
D. Strain all urinary output
First day post-parathyroidectomy, the nurse assessed tingling around the mouth, hands and feet. Which
of the following will the nurse do first?
A. Check for most recent serum calcium level C. Perform tests for Chvostek’s and Trousseau’s
B. Check for signs of hypotension and sign
bradycardia D. Auscultate to check for laryngospasm
Answer: C. Nursing assessment first as compared to laboratory assessment.
Situation 2: Nurse Natsu provides instructions in the surgical pediatric ward. She has cleft lip and palate cases
waiting for their surgery schedules.
Nurse Natsu provides instructions to mothers of an infant with cleft lip and palate regarding the safe
way to feed. Which statement made by the mother would need reinstruction?
A. “I will gently rub the nipple on the lower lip of my child.”
B. “I will use a small-hole nipple to avoid choking.”
C. “I will allow time for my child to swallow.”
D. Much time is needed for breast feeding to avoid accident of aspiration.
Answer. B. The nipple must be enlarged using the cross-cut procedure to be able to prevent risk for aspiration.
(Lippincott, 1591, 9th Ed.)
Nurse Natsu taught the mothers to use the ESSR method of feeding the child with cleft lip. Select the
steps below to illustrate the correct ESSR method.
1. Engorge the nipple 5. Swallow
,2023 NURSING PRACTICE 4 - CARE OF CLIENTS WITH PHYSIOLOGICAL
ANDPSYCHOSOCIAL ALTERATIONS Q&A SUCCESS ASSUARED
2. Enlarge the nipple 6. Reposition the child to the other
3. Simulate the sucking reflex breast
4. STIMULATE THE SUCKING REFLEX 7. Rest to finish swallowing
A. 1,3,5,7 C. 2,3,5,7
B. 2,4,5,6 – TO BE CORRECTED TO 2,4,5,7 D. 1,4,5,6
Answer. B. The ESSR method stands for:
E – enlarge the nipple
S – stimulate the sucking reflex by rubbing nipple on lower lip
S – swallow
R – rest
After cheiloplasty, which of the following is Nurse Natsu’s primary nursing intervention during the post-
operative care to prevent crusting?
A. Administer sedation to prevent picking at the incision wound
B. Keep the infant on NPO
C. Restrain all extremities to prevent rubbing of face and lips
D. Clean suture lines
Answer. D. Only the hands are restrained with an elbow immobilizer. Keeping the infant NPO may cause him to cry
putting pressure on the suture site. Administering sedation is not advised since the child is more susceptible to drug
side effects. (1593, Lippincott)
Which would Nurse Natsu consider her priority nursing intervention immediately following cheiloplasty?
A. Position the child in prone position
B. Assess presence of edema of the tongue, lips and mucus membranes
C. Encourage parents to talk and touch the child
D. Restrain the child’s arms with blanket.
Answer. C. Placing the child in prone position increases pressure on the suture line. Restraints are only applied to the
elbows of the client with manufactured device and not with a blanket. Letter C is a psychosocial intervention and is
not a priority as compared to the other interventions. Assessing presence of edema on tongue, lips and mucus
membranes can interfere with the airway of the client thus is a priority. (749, Pilliteri)
The most effective restraint that Nurse Natsu would use in this case is:
A. Elbow restraint. C. Blanket restraint for the entire
B. Mittens for both hands. body.
D. Blanket restraint for all
extremities.
Answer. A. Blanket restraints are applied only for the elbows and not to all extremities or the entire body. As compared
to mittens and elbow restraints, the least restrictive but effective are elbow restraints. (749, Pilliteri)
Situation 3: Specific surgical interventions for lung cancer may be done when it is detected early. You have
important perioperative responsibilities in caring for patients with lung cancer.
Herman is scheduled to undergo lobectomy. The purpose of closed chest drainage following a lobectomy is:
A. Prevention of mediastinal shift C. Promotion of wound
B. Expansion of the remaining lung healing
D. Facilitation of coughing
Following lobectomy, you can best help Herman to reduce pain during deep breathing and coughing exercises
by:
A. Administering the prescribed analgesic immediately prior to exercises
B. Placing him on his operative side during exercises
C. Splinting his chest with both hands during the exercises
D. Providing rest for six hours before exercises.
, 2023 NURSING PRACTICE 4 - CARE OF CLIENTS WITH PHYSIOLOGICAL
ANDPSYCHOSOCIAL ALTERATIONS Q&A SUCCESS ASSUARED
A. The bronchial suture line may be traumatized C. The tracheobronchial trees are dry.
B. The remaining normal lung needs minimal D. Peter will not be able to tolerate
stimulation. coughing.
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