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A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
- A. Helping the client cope with body image
- B. Maintaining a patent airway.
- C. Preventing injury.
- D. Ensuring adequate nutrition.
Correct Answer: B
Rationale: In a client with esophageal cancer who is experiencing difficulty swallowing, maintaining a patent airway is the highest priority. The client is at risk for aspiration due to the compromised ability to swallow, which could lead to respiratory distress, choking, or aspiration pneumonia. Adequate oxygenation is essential for the client's survival and must be addressed as the priority issue. While coping with body image, preventing injury, and ensuring nutrition are important aspects of care, they are secondary to ensuring the client's airway remains open and clear to prevent respiratory complications.
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Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The disease mentioned in the question is likely myasthenia gravis. Myasthenia gravis is an autoimmune disorder where the body's immune system attacks acetylcholine receptors at the neuromuscular junction. Acetylcholine is a neurotransmitter responsible for transmitting nerve impulses to muscles. In myasthenia gravis, the immune system destroys or blocks the acetylcholine receptor sites on muscle cells, leading to a decrease in the number of functioning receptor sites. This results in muscle weakness and fatigue because the communication between nerves and muscles is impaired. This is why the nurse would base the reply on the knowledge that there is a decreased number of functioning acetyl-choline receptor sites as the underlying cause of the disease.
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client's signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The client's signs and symptoms point towards a diagnosis of peritonitis, which is an inflammation of the peritoneum lining the abdominal cavity. The presence of severe, constant abdominal pain, rigid abdominal muscles, rebound tenderness, hypotension, and tachycardia are all indicative of peritonitis. These symptoms are typically seen when there is an infection or inflammation in the abdominal cavity, leading to fluid shifting from the intravascular space to the peritoneal cavity. This shifting of fluid results in hypovolemia, causing hypotension and tachycardia.
The nurse is reviewing the patient's daily PT and INR levels. The PT level is 26 (normal = 9 to 12 seconds). Which of the ff. actions should the nurse take?
- A. Give the next dose of warfarin when it is ordered to be given.
- B. Inform physician before the next dose of warfarin is given. c.Stop the heparin infusion.
- C. Continue monitoring heparin infusion.
Correct Answer: B
Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.
The age by which the child can make a tower of 9 cubes and imitates circular stroke is
- A. 24 months
- B. 30 months
- C. 36 months
- D. 42 months
Correct Answer: C
Rationale: This milestone is typically achieved around 36 months.
All the following are compatible with the definition of obstructive sleep apnea EXCEPT
- A. episodes of prolonged upper airway obstruction
- B. repeated apnea
- C. 230% reduction in airflow
- D. 2-30% O2 desaturation
Correct Answer: D
Rationale: Oxygen desaturation of 2-30% is too low to define mild-to-moderate sleep apnea.