Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?
- A. Hearing loss, vertigo, and tinnitus
- B. Nausea, vomiting and pain
- C. Nystagmus, headache and vomiting
- D. Nystagmus, vomiting and pain
Correct Answer: A
Rationale: The correct answer is A: Hearing loss, vertigo, and tinnitus. Meniere's disease is characterized by a triad of symptoms: recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus. Vertigo is a spinning sensation, hearing loss affects the inner ear, and tinnitus is ringing in the ear. Nausea, vomiting, pain, nystagmus, or headache are not typically part of the classic triad of Meniere's disease symptoms. Therefore, option A is the most appropriate choice based on the specific symptomatology associated with Meniere's disease.
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During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. This is a common AIDS-related cancer caused by Human Herpesvirus 8 (HHV-8) in immunosuppressed individuals. It presents as purplish lesions on the skin and mucous membranes. Squamous cell carcinoma (A) is not specific to AIDS. Leukemia (B) and Multiple myeloma (C) are not commonly associated with AIDS. Kaposi’s sarcoma is the hallmark cancer seen in AIDS patients due to their weakened immune system.
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?
- A. If the client and her sexual partners are HIV positive, unprotected sex is permitted
- B. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse
- C. Contraceptive methods like birth control pills, implants, and injections are recommended to prevent HIV transmission
- D. The intrauterine device is recommended for a client with HIV
Correct Answer: B
Rationale: The correct answer is B: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
Rationale:
1. Latex condoms create a physical barrier that helps prevent the exchange of bodily fluids containing HIV.
2. Spermicide can further reduce the risk of HIV transmission by killing some viruses and bacteria.
3. Research shows that consistent and correct use of condoms is highly effective in reducing the risk of HIV transmission.
4. Other choices are incorrect:
- A: Unprotected sex between HIV-positive individuals can lead to the transmission of drug-resistant strains or different strains of HIV.
- C: Contraceptive methods like birth control pills do not protect against HIV transmission.
- D: The intrauterine device is not specifically recommended for clients with HIV due to potential risks of infection.
A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.
Which action indicates the nurse is using a PICOT question to improve care for a patient?
- A. Practices nursing based on the evidence presented in court
- B. Implements interventions based on scientific research
- C. Uses standardized care plans for all patients. NursingStoreRN
- D. Plans care based on tradition
Correct Answer: B
Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes.
Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.
An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
- A. Stop the bleeding
- B. Take his vital signs
- C. Check his airway
- D. Find out what happened from eyewitnesses NEUROLOGIC DISORDERS
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.