Nokea
A male client is prescribed medications that depress thrombocytes. The nurse should monitor for which of the ff signs and symptoms in the client?
- A. Sore throat and swollen glands
- B. Pernicious anemia with weakness
- C. Bleeding gums and dark tarry tools
- D. Thickening of blood and bruising
Correct Answer: C
Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function.
A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression.
B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression.
D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.
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Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advise against using analgesics and regional nerve blocks
- D. Encouraged increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: Correct Answer: A - Apply immobilization device after examination by physician
Rationale:
1. Immobilization helps reduce pain and prevent further injury.
2. Physician examination ensures proper diagnosis and treatment plan.
3. Immobilization device may include chest binders or splints for support.
4. It is crucial to follow medical advice to prevent complications.
Summary:
B: Discouraging deep breaths can lead to respiratory complications.
C: Advising against analgesics can increase pain and hinder recovery.
D: Increased fluid intake is important but not directly related to rib fracture care.
What are the periods in life when the need for iron increases?
- A. Pregnancy
- B. Infancy
- C. Old age
- D. Male reproductive years
Correct Answer: A
Rationale: The correct answer is A: Pregnancy. During pregnancy, the need for iron increases significantly to support the growth of the fetus and to prevent maternal anemia. Iron is essential for the production of hemoglobin and for oxygen transport in the blood. In contrast, infants require iron for rapid growth and development, making choice B partially correct. Choice C (Old age) and choice D (Male reproductive years) are incorrect as the need for iron typically decreases in old age and remains relatively stable during male reproductive years.
Which of the following parts of neuron transmits impulses away from the cell body?
- A. Dendrite
- B. Neurolemma
- C. Axon
- D. Synapse
Correct Answer: C
Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons or target cells. It is coated with a myelin sheath, which helps speed up the transmission of impulses. Dendrites (A) receive signals from other neurons, the neurolemma (B) is the outermost layer of the myelin sheath, and the synapse (D) is the junction between two neurons where neurotransmitters are released. Therefore, the axon is the only part of the neuron specifically responsible for transmitting impulses away from the cell body.
The client is taking phenyton (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range?
- A. 5 to 10 mcg/ml.
- B. 20 to 30 mcg/ml.
- C. 10 to 20 mcg/ml.
- D. 30 to 40 mcg/ml.
Correct Answer: A
Rationale: The correct answer is A (5 to 10 mcg/ml) because this range is typically considered therapeutic for phenytoin (Dilantin) for seizure control. Levels below 5 mcg/ml may be subtherapeutic, leading to inadequate seizure control. Levels above 10 mcg/ml can increase the risk of toxicity. Choices B, C, and D are incorrect because they are outside the optimal therapeutic range, leading to either ineffective treatment (B, C) or an increased risk of adverse effects (D). Monitoring drug levels helps ensure the medication's effectiveness while minimizing side effects.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Keep extremities at neutral position. This intervention promotes proper blood flow and reduces the risk of thrombophlebitis by preventing compression or restriction of blood vessels. Removing and reapplying elastic stockings (choice A) can disrupt circulation and increase the risk of thrombophlebitis. Changing the client's position (choice C) may not directly address hemostasis or thrombophlebitis. Using a flotation mattress (choice D) is not specifically focused on maintaining proper positioning of the extremities to promote circulation.