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What is the condition where the lung collapses due to air leaking into the space between the lung and chest wall?
- A. Pneumothorax
- B. Pleural effusion
- C. Pulmonary fibrosis
- D. Lung cancer
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. This condition occurs when air enters the pleural space, causing the lung to collapse. The air disrupts the pressure balance, leading to lung collapse. Pleural effusion (B) is the accumulation of fluid in the pleural space, not air. Pulmonary fibrosis (C) is scarring of lung tissue, unrelated to air leakage. Lung cancer (D) is the abnormal growth of cells in the lung, not directly causing air leakage.
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What is a condition where the heart muscle becomes abnormally enlarged, thickened, or stiffened, often leading to heart failure?
- A. Cardiomyopathy
- B. Pericarditis
- C. Aortic stenosis
- D. Mitral valve prolapse
Correct Answer: A
Rationale: The correct answer is A: Cardiomyopathy. Cardiomyopathy is a condition characterized by abnormal enlargement, thickening, or stiffening of the heart muscle, which can lead to heart failure. This condition directly affects the heart muscle itself, causing it to function improperly. Pericarditis (B) is inflammation of the pericardium, the outer lining of the heart, not the heart muscle. Aortic stenosis (C) and Mitral valve prolapse (D) involve issues with heart valves, not the heart muscle itself. Therefore, A is the correct choice as it directly addresses the abnormal changes in the heart muscle leading to heart failure.
The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?
- A. Place the tablet under the tongue and let it dissolve completely.
- B. Swallow the tablet whole with a glass of water.
- C. Chew the tablet and then swallow it.
- D. Take one tablet every 5 minutes until pain is relieved.
Correct Answer: A
Rationale: The correct answer is A: Place the tablet under the tongue and let it dissolve completely. Nitroglycerin is absorbed quickly through the oral mucosa, providing rapid relief for chest pain. Placing it under the tongue allows for direct absorption into the bloodstream. Swallowing the tablet whole (B) would delay absorption. Chewing the tablet (C) would cause rapid absorption and possibly lead to a drop in blood pressure. Taking one tablet every 5 minutes (D) is not recommended as it can lead to hypotension. Therefore, option A is the most appropriate instruction for the client.
In third-degree atrioventricular block, all sinus impulses fail to activate the ventricles. This will be detected by
- A. A highly variable PR interval
- B. Regular PP intervals
- C. A slow heart rate
- D. Regular RR intervals
Correct Answer: C
Rationale: Slow heart rate reflects lack of conduction from atria to ventricles.
What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?
- A. Autoimmune disease
- B. Infectious disease
- C. Allergic reaction
- D. Degenerative disease
Correct Answer: A
Rationale: The correct answer is A: Autoimmune disease. In autoimmune diseases, the immune system mistakenly attacks the body's tissues, leading to inflammation and damage. This occurs due to a breakdown in immune tolerance, resulting in the immune system targeting self-antigens. This leads to chronic inflammation and tissue damage. In contrast, infectious diseases are caused by pathogens, allergic reactions are responses to harmless substances, and degenerative diseases involve the gradual deterioration of tissues over time. Therefore, autoimmune disease best fits the description provided in the question.
The nurse is caring for a client on warfarin with an INR of 1.8. What is the most appropriate action?
- A. Increase the dose of warfarin.
- B. Administer vitamin K.
- C. Hold the warfarin and notify the healthcare provider.
- D. Monitor the client's INR closely.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's INR closely. An INR of 1.8 indicates the client is below the therapeutic range for warfarin. By closely monitoring the client's INR, the nurse can assess the effectiveness of the current dosage and make informed decisions about potential adjustments. Increasing the dose of warfarin (Choice A) without monitoring could lead to over-anticoagulation. Administering vitamin K (Choice B) is not indicated unless the client is experiencing severe bleeding. Holding the warfarin and notifying the healthcare provider (Choice C) may be necessary in some cases, but monitoring is the initial appropriate action to evaluate the situation before making changes.