Nokea
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
You may also like to solve these questions
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: C
Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient’s sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: Step-by-step rationale:
1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination.
2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately.
3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits.
4. It also provides insight into the client's motor function and coordination abilities.
Summary:
- Choice B is incorrect because it focuses on sensory functions rather than motor functions.
- Choice C assesses fine motor skills, not grip strength and coordination.
- Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
Pulmonary edema is characterized by:
- A. Elevated left ventricular and-diastolic
- B. Increased hydrostatic pressure
- C. All of the above alterations
- D. A rise in pulmonary venous pressure
Correct Answer: C
Rationale: Rationale:
1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation.
2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema.
3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure.
Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. Problem statement
- B. Defining characteristics
- C. Etiology of the problem
- D. Outcomes criteria
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.