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A 54-year-old man has a myocardial infarction, resulting in left-sided heart failure. The nurse caring for the man is most concerned that he will develop edema in what area of the body.
- A. Peripheral.
- B. Pulmonary.
- C. Liver.
- D. Abdominal.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary. Left-sided heart failure leads to the accumulation of fluid in the lungs, causing pulmonary edema. As the heart fails to pump effectively, blood backs up into the pulmonary circulation, leading to increased pressure in the blood vessels of the lungs. This results in fluid leakage into the alveoli, impairing gas exchange and causing symptoms like shortness of breath and coughing. Peripheral edema (choice A) occurs in right-sided heart failure due to fluid accumulation in the extremities. Liver congestion (choice C) can lead to hepatomegaly but is not the primary concern in this case. Abdominal edema (choice D) may occur in severe cases but is not as immediate a concern as pulmonary edema in left-sided heart failure.
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What assessment finding would indicate the patient's left-sided heart failure is worsening?
- A. Increased jugular venous pressure.
- B. Liver enlargement.
- C. Increased pulse rate.
- D. Increased crackles in lung fields.
Correct Answer: D
Rationale: The correct answer is D: Increased crackles in lung fields. Worsening left-sided heart failure causes fluid to accumulate in the lungs, leading to crackles on auscultation. Increased jugular venous pressure (A) is more indicative of right-sided heart failure. Liver enlargement (B) is a sign of congestive hepatomegaly, common in right-sided heart failure. Increased pulse rate (C) may indicate heart failure exacerbation but is not specific to left-sided failure. Therefore, choice D is the best indicator of worsening left-sided heart failure.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.
A student asks the pharmacology instructor to explain the action of anticholinergic agents. What would be the instructor's best response?
- A. They compete with serotonin for muscarinic acetylcholine receptor sites.
- B. They increase norepinephrine at the neuromuscular junction.
- C. They block nicotinic receptors.
- D. They act to block the effects of the parasympathetic nervous system.
Correct Answer: D
Rationale: The correct answer is D: They act to block the effects of the parasympathetic nervous system. Anticholinergic agents inhibit the action of acetylcholine, the primary neurotransmitter of the parasympathetic nervous system. By blocking muscarinic acetylcholine receptors, these agents reduce parasympathetic stimulation, leading to effects such as decreased salivation, decreased GI motility, and pupil dilation.
Choice A is incorrect because anticholinergic agents do not compete with serotonin for receptor sites; they primarily target acetylcholine receptors. Choice B is incorrect as anticholinergic agents do not directly affect norepinephrine levels at the neuromuscular junction. Choice C is incorrect because anticholinergic agents primarily target muscarinic receptors, not nicotinic receptors.
A patient has been taking Sertraline (Zoloft) 20mg/ml oral concentrate 1ml daily for several weeks and reports being unable to sleep well. What will the nurse do next?
- A. Ask the patient what time of day the medication is taken.
- B. Recommend asking the provider about weekly dosage.
- C. Counsel the patient to take the medication at bedtime.
- D. Suggest that the patient request a lower dose.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient what time of day the medication is taken. This is because insomnia can be a common side effect of sertraline, and taking it at a different time of day may help alleviate this issue. By understanding the timing of the medication intake, the nurse can assess if adjusting the administration time may improve the patient's sleep. Option B is not directly related to addressing the sleep concern. Option C may help but does not address the timing issue. Option D is premature without assessing the current timing.
Which of the following is an adverse reaction to topical nasal steroid?
- A. Rebound effect.
- B. Local ulceration.
- C. Increased nasal drainage.
- D. Suppression of healing.
Correct Answer: B
Rationale: The correct answer is B: Local ulceration. Topical nasal steroids can cause local irritation, leading to ulceration in the nasal mucosa. This occurs due to the steroid's potent anti-inflammatory effects on the nasal tissues. Rebound effect (choice A) is associated with nasal decongestant sprays, not nasal steroids. Increased nasal drainage (choice C) is not typically an adverse reaction to nasal steroids. Suppression of healing (choice D) is not a common side effect of topical nasal steroids.