Nokea
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: C
Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised.
A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis.
B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention.
D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.
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A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis.
A: Hyperventilation would lead to respiratory alkalosis, not acidosis.
B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis.
D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis.
In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mE⁺q/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.
Which of the ff are the most significant symptoms of Hodgkin’s disease category B? Choose all that apply
- A. Fever
- B. Anemia
- C. Night sweats
- D. Thrombocytopenia
Correct Answer: C
Rationale: The correct answer is C: Night sweats. In Hodgkin's disease category B, the presence of night sweats signifies more advanced disease and higher tumor burden. Night sweats are a B-symptom, along with fever and weight loss, indicating systemic symptoms. Anemia (choice B) and thrombocytopenia (choice D) are not specific to Hodgkin's disease category B and can be present in various other conditions. Fever (choice A) is not exclusive to Hodgkin's disease category B and can occur in many infections and inflammatory conditions. Night sweats are specifically associated with Hodgkin's disease and are a key indicator of disease severity in this context.
Which of the following medications can be used to quickly reduce SOB in a crisis situation for a patient with end-stage respiratory disease?
- A. Oral cortisone
- B. IV morphine
- C. IM meperidine (Demerol)
- D. IV propanolol (Inderal)
Correct Answer: B
Rationale: Step 1: IV morphine is the correct choice as it is a potent analgesic and has a rapid onset of action to reduce shortness of breath (SOB) in a crisis situation.
Step 2: Oral cortisone (A) is not suitable for quick relief of SOB as it has a slower onset of action.
Step 3: IM meperidine (C) is an opioid analgesic but not commonly used for managing SOB in end-stage respiratory disease.
Step 4: IV propranolol (D) is a beta-blocker and not indicated for immediate relief of SOB in a crisis situation.