Nokea
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.
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Bacterial meningitis alters intracranial physiology, causing:
- A. Cerebral edema
- B. Raised intracranial pressure
- C. Increased permeability of the blood-barrier
- D. All of the above changes
Correct Answer: D
Rationale: The correct answer is D. Bacterial meningitis alters intracranial physiology by causing cerebral edema, raised intracranial pressure, and increased permeability of the blood-brain barrier. Cerebral edema is the accumulation of fluid in the brain tissue, leading to increased pressure. Raised intracranial pressure occurs due to the inflammation and swelling caused by the infection. Increased permeability of the blood-brain barrier allows substances to pass through that would normally be blocked, contributing to the inflammatory response. Therefore, all of these changes are interconnected and commonly observed in bacterial meningitis cases. Choices A, B, and C individually describe specific alterations seen in bacterial meningitis but do not encompass the full spectrum of changes that occur, making them incorrect options.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: B
Rationale: The correct answer is B (AB). AB blood type is the rarest because it is a result of inheriting both A and B alleles, making it less common in the population. AB individuals can only receive blood from other AB individuals due to their unique antigens. Blood types A, B, and O are more common in the population, with O being the most common as it is the universal donor. Blood type A and B are more common than AB since they only require one allele for their respective antigens. Thus, the rarity of AB blood type is due to the inheritance of both A and B alleles, making it the least common among the choices provided.
A client has squamous cell cancer of the right lung that has metastasized to the brain. In addition to chemotherapy for lung cancer, the physician prescribes lomustine (CeeNU), 100 mg/m2 as a single dose, to treat the brain metastasis. What are the major administration and excretion routes of lomustine?
- A. Oral administration and urinary
- B. I.V. administration and urinary excretion
- C. I.V administration and fecal excretion
- D. Oral administration and fecal excretion
Correct Answer: B
Rationale: The correct answer is B: I.V. administration and urinary excretion. Lomustine is typically administered intravenously, allowing for rapid systemic distribution. The drug is metabolized in the liver and excreted primarily through the kidneys, thus the urinary route. This choice is correct as lomustine's pharmacokinetics align with this pattern.
A: Oral administration and urinary - While some drugs are administered orally, lomustine is not typically given orally due to poor bioavailability.
C: I.V. administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
D: Oral administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
Which of the following risk factors presents the greatest threat for respiratory disease?
- A. Smoking
- B. Exposure to radiation
- C. High-fat diet
- D. Alcohol consumption
Correct Answer: A
Rationale: The correct answer is A: Smoking. Smoking presents the greatest threat for respiratory disease due to the harmful chemicals in tobacco that can damage the lungs and lead to conditions like COPD and lung cancer. Smoking is a well-known risk factor for various respiratory issues. Exposure to radiation (B) can increase cancer risk but is not as directly linked to respiratory diseases. High-fat diet (C) may impact overall health but is not a primary risk factor for respiratory diseases. Alcohol consumption (D) can contribute to respiratory issues, but smoking is considered the most significant risk factor.
The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the ff. interventions is most important for the nurse to do before the procedure?
- A. Explain the procedure to the patient’s family
- B. Observe the patient for bleeding
- C. Administer an analgesic to the patient
- D. Drape the biopsy site
Correct Answer: B
Rationale: The correct answer is B: Observe the patient for bleeding. Before a bone marrow biopsy, it is crucial to monitor the patient for bleeding tendencies as the procedure can cause bleeding. This step ensures early detection and prompt intervention if bleeding occurs.
Explanation for other choices:
A: Explaining the procedure to the family is important for informed consent but not the most crucial before the procedure.
C: Administering an analgesic may be necessary for pain management but monitoring for bleeding takes precedence.
D: Draping the biopsy site is important for maintaining a sterile field but does not directly impact patient safety like monitoring for bleeding.