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A newly diagnosed patient asks what asthma is. Which of the ff. explanations by the nurse is correct?
- A. “Your airways are inflamed and spastic.”
- B. “”You have fluid in your lungs that is causing shortness of breath.”
- C. “Your airways are stretched and non-functional.”
- D. “You have a low-grade infection that keeps your bronchial tree irritated.”
Correct Answer: A
Rationale: The correct answer is A because asthma is characterized by inflammation and bronchoconstriction of the airways, leading to difficulty breathing. This explanation accurately describes the pathophysiology of asthma.
Explanation for other choices:
B: Fluid in the lungs is more indicative of conditions like pneumonia or pulmonary edema, not asthma.
C: Asthma involves airway constriction and inflammation, not stretching and non-functionality.
D: Asthma is not caused by infection but rather triggered by factors like allergens or irritants.
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The patient asks the nurse, “What is hypertension?” Which of the following is the best response to explain hypertension?
- A. “It is measured as the heart pumps blood into the arteries.”
- B. “It is higher than normal on two separate occasions.”
- C. “It is regulated by stress, activity, and emotions.”
- D. “It is determined by peripheral vascular resistance.”
Correct Answer: D
Rationale: The correct answer is D because hypertension is primarily determined by peripheral vascular resistance, which refers to the resistance in the blood vessels that the heart must overcome to pump blood effectively. This is a key factor in the development of high blood pressure. Choice A is incorrect as it simplifies the concept to just the pumping action of the heart. Choice B is incorrect because hypertension is not just about having high readings on separate occasions but rather a sustained elevation in blood pressure. Choice C is incorrect as stress, activity, and emotions can influence blood pressure but are not the sole determinants of hypertension.
Mr. Galino is diagnosed to have Raynaud’s disease. Nurse Oliver gives instructions to the client to stop smoking because it causes:
- A. cyanosis and necrosis
- B. vasoconstriction, vasospasms
- C. decreased blood oxygen content
- D. pain and tingling
Correct Answer: B
Rationale: The correct answer is B: vasoconstriction, vasospasms.
1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress.
2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further.
3. This can worsen symptoms for individuals with Raynaud's disease.
4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
- A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
- B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
- C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
- D. Alteration in the size, shape, and organization of differentiated cells
Correct Answer: D
Rationale: The correct answer is D because dysplasia refers to the alteration in the size, shape, and organization of differentiated cells. Dysplasia is an abnormal growth or development of cells that can be a precursor to cancer. It is characterized by changes in cell size, shape, and organization, which can be seen in Papanicolaou tests.
Choice A is incorrect because it describes an undifferentiated tumor, not dysplasia. Choice B is incorrect as it describes hyperplasia, not dysplasia. Choice C is incorrect as it refers to metaplasia, not dysplasia.
In summary, dysplasia is specifically about the abnormal changes in the appearance and organization of differentiated cells, making choice D the correct definition.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings.
Summary of other choices:
B: Planning comes after diagnosis and involves setting goals and creating a plan of care.
C: Implementation follows planning and involves carrying out the plan of care.
D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.
The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.