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A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
- A. A hemolytic reaction to mismatched blood
- B. A hemolytic reaction to Rh-incompatible blood
- C. A hemolytic allergic reaction caused by bacterial contamination of donor blood
- D. None of the above
Correct Answer: A
Rationale: The client is likely experiencing a hemolytic reaction to mismatched blood due to the symptoms of chills, dyspnea, and urticaria occurring shortly after beginning the blood transfusion. These symptoms are classic signs of a transfusion reaction, especially a hemolytic reaction where the recipient's immune system attacks the transfused red blood cells. This can happen if the donor blood is not compatible with the recipient's blood type, leading to a severe reaction. It is crucial to report this immediately to the physician to halt the transfusion and provide appropriate treatment to the client.
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The most effective pharmacologic agent for the treatment of Parkinson's disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: Levodopa is considered the most effective pharmacologic agent for the treatment of Parkinson's disease. Levodopa is a precursor of dopamine, a neurotransmitter that is deficient in Parkinson's disease. By increasing dopamine levels in the brain, levodopa helps to alleviate the motor symptoms of Parkinson's disease, such as tremors, stiffness, and slowness of movement. Levodopa is often combined with another medication called carbidopa to enhance its effectiveness and reduce side effects. While other medications like selegiline, pergolide (Permax), and amantadine (Symmetrel) can also be used to manage Parkinson's disease symptoms, levodopa remains the primary and most effective treatment option for many patients.
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: Macular degeneration primarily affects the macula, which is responsible for central vision. Therefore, symptoms typically include loss of central vision, decreased ability to distinguish colors, and loss of near vision. Loss of peripheral vision is not a common symptom associated with macular degeneration. Instead, it is more commonly seen in conditions affecting the peripheral retina, such as retinitis pigmentosa.
Bell's palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: Bell's palsy is a cranial nerve disorder characterized by weakness or paralysis of the facial muscles due to inflammation, compression, or damage to the seventh cranial nerve - the facial nerve. The facial nerve controls the muscles responsible for facial expressions and functions like smiling, closing the eyes, and raising the eyebrows. Symptoms of Bell's palsy can include drooping of one side of the face, difficulty in closing one eye, drooling, impaired taste, and difficulty in smiling.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- A. Wash the radiation site vigorously with soap and water to remove dead cells.
- B. Eat a diet high in protein and calories to optimize tissue repair.
- C. Apply coo! compresses to the radiation site to reduce edema,
- D. Drink warm fluids throughout the day to relieve discomfort in swallowing
Correct Answer: B
Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.