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A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning, and numbness
- D. cold, aching, burning, and numbness
Correct Answer: A
Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.
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A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screening on the patient.
- D. Request the physician on-call to assess the patient.
Correct Answer: B
Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
- A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
- B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
- C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
- D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus
Correct Answer: B
Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).
Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest.
Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production.
Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.
During a petit mal seizure in the clinic, what should be the highest priority?
- A. Provide a safe environment free of obstructions in the immediate area
- B. Call a code
- C. Contact the patient's physician
- D. Prevent excessive movement of the extremities
Correct Answer: A
Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.
A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A. An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
- B. A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
- C. A 7-year-old boy has been having a low fever and headache for the past 3 days and has a history of an anterior knee wound.
- D. A 7-year-old girl who had a cast on her right ankle is complaining of itching.
Correct Answer: A
Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.
Which physiologic mechanism best describes the function of the sodium-potassium pump?
- A. active transport
- B. diffusion
- C. filtration
- D. osmosis
Correct Answer: A
Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice C) involves the movement of solutes based on pressure gradients. Osmosis (choice D) is the movement of water across a semipermeable membrane.