Nokea
A client is brought to the emergency department after a motor vehicle accident in which she suffered a spinal cord injury at the level of C5. Which of the following assessments should be the priority?
- A. Monitoring urinary output
- B. Monitoring heart rate and rhythm
- C. Monitoring respiratory rate
- D. Monitoring the client's pain levels
Correct Answer: B
Rationale: The correct answer is monitoring heart rate and rhythm. With a C5 spinal cord injury, monitoring heart rate and rhythm is crucial as it can impact autonomic regulation. This level of injury can affect cardiac function due to the disruption of sympathetic nerve fibers. Monitoring urinary output may be important to assess for urinary retention, but it is not the priority in this scenario. While monitoring respiratory rate is essential in all patients, in this case, cardiovascular stability takes precedence. Pain management is important but is not the priority when assessing a client with a C5 spinal cord injury.
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As you are walking in the park, a huge black Labrador runs up to you and places his paws on your shoulders. Immediately your heart starts racing, you feel palpitations, anxiety, and your hands become a little shaky. The nurse knows that this response is primarily caused by:
- A. cerebral cortex.
- B. somatic nervous system.
- C. limbic system.
- D. autonomic nervous system.
Correct Answer: D
Rationale: The autonomic nervous system controls involuntary bodily functions like heart rate, respiration, and sweating. In the given scenario, the 'fight or flight' response is activated, leading to increased heart rate, palpitations, anxiety, and shaky hands. The cerebral cortex is involved in conscious thought processes and decision-making, not the immediate physiological response observed here. The somatic nervous system regulates voluntary movements, while the limbic system is responsible for emotions and memory, but the autonomic nervous system is primarily responsible for the physiological responses seen in this situation.
What symptoms would the nurse expect to see in a client with chronic obstructive pulmonary disease (COPD)?
- A. Dyspnea on exertion
- B. Normal lung sounds
- C. Normal arterial blood gases
- D. Onset of the disease during young adulthood
Correct Answer: A
Rationale: The correct answer is A: Dyspnea on exertion. COPD typically manifests with symptoms like dyspnea on exertion due to impaired lung function. This symptom is a result of the airways being obstructed and the lungs not being able to expel air effectively. Choices B and C are incorrect because in COPD, abnormal lung sounds such as wheezing, crackles, or diminished breath sounds are often heard upon auscultation, and arterial blood gases are usually abnormal, showing low oxygen levels and high carbon dioxide levels. Choice D is incorrect as COPD is more commonly diagnosed in individuals over 40 who have a history of smoking or exposure to lung irritants.
What is a characteristic of coronary artery disease (CAD)?
- A. The build-up of infectious by-products in the lymph nodes
- B. Insufficient delivery of oxygenated blood to the myocardium
- C. Insufficient delivery of carbon dioxide to the lungs
- D. The build-up of bile in the stomach and gallbladder
Correct Answer: B
Rationale: The correct characteristic of coronary artery disease (CAD) is the insufficient delivery of oxygenated blood to the myocardium. CAD is a condition where the coronary arteries become narrowed or blocked, leading to reduced blood flow to the heart muscle. This lack of oxygenated blood can result in chest pain, known as angina, and if a coronary artery becomes completely blocked, it can cause a heart attack. Choices A, C, and D are incorrect. Choice A refers to an issue related to the lymphatic system, choice C is about gas exchange in the lungs, and choice D describes a problem with bile accumulation in the digestive system, none of which are characteristics of CAD.
What causes type I diabetes?
- A. Overproduction of insulin from the beta cells of the pancreas
- B. Destruction of the beta cells within the pancreas, resulting in an inability to produce insulin
- C. Loss of insulin receptors on the target cells, resulting in insulin resistance
- D. A pituitary tumor in the brain, resulting in increased antidiuretic hormone production
Correct Answer: B
Rationale: Type I diabetes is caused by the destruction of the beta cells in the pancreas, leading to an inability to produce insulin. This results in a lack of insulin, leading to hyperglycemia. Choice A is incorrect as type I diabetes is characterized by a deficiency of insulin production, not overproduction. Choice C describes the pathophysiology of type 2 diabetes, where insulin receptors become less responsive to insulin. Choice D is unrelated to type I diabetes as it describes a pituitary tumor causing increased antidiuretic hormone production.
What condition can be caused by an excessive amount of growth hormone released by the pituitary gland in childhood?
- A. Acromegaly
- B. Gigantism
- C. Syndrome of inappropriate antidiuretic hormone
- D. Dwarfism
Correct Answer: B
Rationale: Gigantism is the correct answer. It is a condition caused by excessive growth hormone release before the epiphyseal plates close, leading to abnormal growth. Acromegaly (choice A) is caused by excess growth hormone after the epiphyseal plates close, resulting in enlargement of bones and tissues. Syndrome of inappropriate antidiuretic hormone (choice C) is characterized by the excessive release of antidiuretic hormone, leading to water retention and dilutional hyponatremia. Dwarfism (choice D) is a condition characterized by significantly below-average height.