Nokea
A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
- A. Bacterial infection
- B. High-fat diet
- C. Heredity
- D. Autoimmune reaction
Correct Answer: D
Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.
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Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections.
- Choice B: Cognitive problems, is not directly related to lymphocyte levels.
- Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes.
- Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.
An adult had a total thyroidectomy. Which statement by the client demonstrates to the nurse an adequate understanding of long term care?
- A. “I will need to take replacement hormones for the rest of my life.”
- B. “ I should try to avoud stress and be alert for signs of recurrent hyperthyroidism.”
- C. “Thank goodness, this is over! I will never have to worry about throid problems again.”
- D. “ I should increase my caloric intake to replace what I lost during the surgery.”
Correct Answer: A
Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used.
Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly.
Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride.
Summary:
- Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration.
- Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride.
- Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: A
Rationale: The correct answer is A because decorticate posturing is characterized by flexion of both upper and lower extremities. This occurs due to damage to the cerebral hemispheres, resulting in abnormal muscle contractions. Choice B describes decerebrate posturing, which is associated with extension of elbows and knees. Choice C is incorrect as it describes abnormal posturing seen in other conditions. Choice D is also incorrect as it describes a different type of abnormal posturing.
The nurse notes that a client’s wound has not improved despite consistent wound care as outlined in the care plan. What should the nurse do next?
- A. Reassess the wound and client’s condition.
- B. Discontinue the current care plan.
- C. Increase the frequency of wound dressing changes.
- D. Refer the client to a specialist immediately.
Correct Answer: A
Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement.
Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing.
Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice.
Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care.
Summary:
Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.