Nokea
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: B
Rationale: - **Encourage a liberal fluid intake (B):** It is essential to maintain hydration after a lumbar puncture to help prevent or alleviate a headache, which may occur due to a decrease in cerebrospinal fluid (CSF) pressure. Adequate hydration can help reduce the chances of a post-lumbar puncture headache.
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Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.
If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
- A. Left atrial atrophy
- B. Left ventricular hypertrophy
- C. Right atrial atrophy
- D. Right ventricular hypertrophy
Correct Answer: D
Rationale: Elevated pulmonary vascular pressures can lead to pulmonary hypertension, which causes increased pressure in the right side of the heart. The right ventricle has to work harder to pump blood against the increased resistance in the pulmonary circulation. Over time, this can result in the development of right ventricular hypertrophy as the muscle of the right ventricle thickens in response to the increased workload. This is a compensatory mechanism to try to maintain cardiac output despite the increased pressure in the pulmonary circulation. Left atrial atrophy, left ventricular hypertrophy, and right atrial atrophy are not typically associated with elevated pulmonary vascular pressures.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
- A. Make sure he drinks 8 glasses of water a day.
- B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
- C. Look for signs of hyperchloremia
- D. Observe for neurologic changes
Correct Answer: B
Rationale: The 78-year-old male in this scenario is at risk for electrolyte imbalances due to prolonged exposure to high temperatures while taking thiazide diuretics, commonly prescribed for hypertension. The low potassium level (K 3.7 mEq/L) and low sodium level (Na 129 mEq/L) in his lab results are indicative of potential electrolyte disturbances, especially considering his age and medication. These electrolyte imbalances can lead to symptoms like fatigue, muscle weakness, restlessness, and flushed skin, which are signs of hyponatremia and hypokalemia.
The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula is less critical if the baby is gaining weight adequately.