Nokea
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler’s
- B. Modified trendelenburg
- C. Side lying
- D. Supine NERVOUS SYSTEM
Correct Answer: C
Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway.
Incorrect choices:
A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure.
B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions.
D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure.
Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.
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A woman sees her primary care provider because of extreme fatigue for the past 2 months; she difficulty lifting even light objects. Her physician suspects myasthenia gravis. Which of the ff. tests should the nurse anticipate to confirm this diagnosis?
- A. Mestinon test
- B. Pulmonary function studies
- C. Quinine tolerance test
- D. Tensilon test
Correct Answer: D
Rationale: The correct answer is D: Tensilon test. The Tensilon test involves administering edrophonium (Tensilon) to temporarily improve muscle weakness in myasthenia gravis patients, confirming the diagnosis. Other choices are incorrect: A (Mestinon test) is not a standard diagnostic test for myasthenia gravis, B (Pulmonary function studies) are not specific for myasthenia gravis, and C (Quinine tolerance test) is not a relevant test for this condition.
Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Check the area after the next menstrual
- C. Squeeze the nipple to check for period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.
The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy
- A. AH of these (a, b, c)
- B. Weakened immune system impairs resistance to infection
- C. Infection cannot be treated effectively
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death.
Summary of Other Choices:
B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections.
C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment.
Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.