Nokea
A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client:
- A. If he has improved circulation in the legs
- B. If he can wiggle his toes
- C. If he is urinating more frequently
- D. If he is less dizzy
Correct Answer: A
Rationale: Pentoxifylline improves blood flow by reducing blood viscosity and increasing erythrocyte flexibility, alleviating intermittent claudication. Asking about improved leg circulation (e.g., reduced pain or increased walking distance) assesses its effectiveness. Toe movement, urination, and dizziness are unrelated to its therapeutic action.
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Which of the following is a late symptom of polycythemia vera?
- A. Headache.
- B. Dizziness.
- C. Pruritus.
- D. Shortness of breath.
Correct Answer: C
Rationale: Pruritus, especially after warm baths, is a late symptom of polycythemia vera due to increased histamine release from elevated basophils. Headache, dizziness, and shortness of breath are earlier symptoms related to increased blood viscosity and hypermetabolism.
The nurse explains to the client with pain that the purpose of biofeedback is to enable him to exert control over his physiologic processes by:
- A. Regulating the body processes through electrical control.
- B. Shocking himself when an undesirable response is elicited.
- C. Monitoring the body processes for the therapist to interpret.
- D. Translating the signals of his body processes into observable forms.
Correct Answer: D
Rationale: Biofeedback translates physiological signals (e.g., heart rate) into observable forms, allowing the client to control them consciously. It does not involve electrical shocks, therapist interpretation, or direct electrical regulation.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
- A. Dust particles.
- B. Droplet nuclei.
- C. Water.
- D. Eating utensils.
Correct Answer: B
Rationale: Tuberculosis is primarily spread through droplet nuclei produced when an infected person coughs or sneezes. Dust, water, and utensils are not significant transmission routes.
Which of the following findings would suggest pneumothorax in a trauma victim?
- A. Pronounced crackles.
- B. Inspiratory wheezing.
- C. Dullness on percussion.
- D. Absent breath sounds.
Correct Answer: D
Rationale: Absent breath sounds on the affected side suggest pneumothorax due to air in the pleural space. Crackles, wheezing, and dullness are more indicative of other conditions.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.