A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

Abdominal pain

Urticaria of the arms

Persistent nasal drainage

Pain during urination

Answer and Explanation

The Correct Answer is C

Choice A reason: Abdominal pain is not a typical complication of hypophysectomy and is less urgent compared to other potential complications.

Choice B reason: Urticaria (hives) of the arms can indicate an allergic reaction but is not directly related to the surgery. It requires attention but is not the most critical finding.

Choice C reason: Persistent nasal drainage following hypophysectomy could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. CSF leaks require immediate medical attention to prevent meningitis and other complications.

Choice D reason: Pain during urination is not directly related to the hypophysectomy and is less urgent compared to other potential complications.

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Correct Answer is C

Explanation

Choice A reason: Symmetrical joint pain that is relieved with rest is more characteristic of osteoarthritis, not rheumatoid arthritis. RA typically involves persistent, symmetrical joint pain and inflammation.

Choice B reason: Unilateral pain in the weight-bearing joints is not characteristic of RA. Rheumatoid arthritis generally affects joints symmetrically on both sides of the body.

Choice C reason: Symmetrical joint pain is a hallmark of rheumatoid arthritis. RA causes inflammation and pain in multiple joints, typically affecting the same joints on both sides of the body.

Choice D reason: Hypoglycemia is not related to rheumatoid arthritis. RA primarily involves joint inflammation and systemic symptoms like fatigue and fever but does not directly impact blood sugar levels.

A. Defibrillation B. Vagal maneuvers C. Radiofrequency catheter ablation D. Administration of Atropine

Correct Answer is A

Explanation

Choice A reason: Defibrillation is the appropriate intervention for pulseless ventricular tachycardia (VT). It delivers an electrical shock to the heart to restore a normal rhythm. Immediate defibrillation is crucial for survival as it can terminate the arrhythmia and allow the heart to re-establish an effective rhythm.

Choice B reason: Vagal maneuvers, such as the Valsalva maneuver, are used to terminate supraventricular tachycardias but are ineffective for pulseless VT. These maneuvers stimulate the vagus nerve to slow the heart rate but do not provide the necessary intervention for life-threatening arrhythmias like pulseless VT.

Choice C reason: Radiofrequency catheter ablation is a procedure used to treat recurrent arrhythmias by destroying abnormal electrical pathways in the heart. It is not an emergency intervention for pulseless VT. Defibrillation is needed to address the immediate, life-threatening situation.

Choice D reason: Administration of atropine is not indicated for pulseless VT. Atropine is used to treat bradycardia by increasing heart rate, but it does not address the underlying cause of VT. Defibrillation is the correct immediate intervention for pulseless VT.

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A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Correct Answer is A

Explanation

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