Nokea
A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY
- A. Central nervous system
- B. Integumentary system
- C. Respiratory system
- D. Renal system
- E. Gastrointestinal system
Correct Answer: B,C,E
Rationale: The correct answer includes the integumentary system (B), respiratory system (C), and gastrointestinal system (E) as potential portals of entry for anthrax. Anthrax can enter the body through broken skin (integumentary system), inhalation of spores (respiratory system), or ingestion of contaminated food/water (gastrointestinal system). The central nervous system (A) and renal system (D) are not typical routes of entry for anthrax. Central nervous system is not a common portal for anthrax entry, and the renal system is not a primary site for anthrax spore invasion.
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A nurse is working with the hospital disaster plan with the emergency operations committee. The nurse is aware that nursing is involved in which components of the disaster plan? SELECT ALL THAT APPLY
- A. Identification of resources to meet anticipated needs
- B. Participation in comprehensive annual drills
- C. Internal and external communications
- D. Performing duties outside the typical job description
- E. Development of a decontamination plan
Correct Answer: A,B,C,E
Rationale: The correct choices are A, B, C, and E. A: Nurses identify resources needed during a disaster to meet patient needs. B: Nurses participate in drills to practice response protocols. C: Nurses play a role in both internal communication within the healthcare facility and external communication with outside agencies. E: Nurses are involved in the development of decontamination plans to ensure safety. D: While nurses may perform duties outside their normal scope during a disaster, it is not a specific component of the disaster plan. Therefore, it is incorrect.
A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
- A. Chew tablet well before swallowing
- B. If you experience chest pain, call your physician immediately
- C. Take daily to prevent headaches
- D. Repeat dose in 1 hour for unrelieved headache
Correct Answer: B
Rationale: The correct answer is B: If you experience chest pain, call your physician immediately. This is crucial because Sumatriptan can sometimes cause chest pain or tightness as a side effect, which could indicate a serious issue like a heart problem. Instructing the client to contact their physician immediately ensures prompt medical attention if such symptoms occur, potentially preventing a serious complication. Choices A, C, and D are incorrect. A: Chewing Sumatriptan tablets is not recommended as it may alter the drug's absorption rate. C: Sumatriptan is not meant to be taken daily for headache prevention; it is used for acute migraine attacks. D: Repeating the dose in 1 hour is not advised as it can increase the risk of side effects and medication overuse headaches.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure (ICP)?
- A. Hypertension
- B. Tinnitus
- C. Hypotension
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Increased ICP can lead to hypertension due to the body's compensatory mechanisms trying to maintain cerebral perfusion pressure. Hypertension helps to ensure an adequate blood flow to the brain despite the increased pressure. Tinnitus (B) is not typically associated with increased ICP. Hypotension (C) is more likely to occur in cases of shock or hypovolemia. Tachycardia (D) may be present in response to increased ICP, but hypertension is a more specific manifestation of increased intracranial pressure.
The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY
- A. I may experience urinary incontinence
- B. I should not exercise because this may trigger an exacerbation
- C. I need to check the water temperature before I take a bath
- D. I may experience visual disturbances
- E. I should alternate the eye patch every other day to help with the double vision
Correct Answer: B,E
Rationale: Correct Answer: B, E
Rationale:
- Choice B is incorrect because exercise is beneficial for MS clients, improving strength and mood. Avoiding exercise is not recommended.
- Choice E is incorrect because alternating the eye patch can worsen double vision. Consistent use of the eye patch is more effective.
- Choices A, C, and D are correct statements that indicate proper understanding of MS symptoms and self-care.
A nurse is caring for a client scheduled for a functional assessment who asks, 'What is the purpose of this assessment?' How should the nurse most appropriately respond to the client?
- A. It is a test that determines which activities you feel most comfortable performing
- B. It is a tool that is used to determine your maximum level of self-sufficiency
- C. It is a tool that is used to assess what services you will need a home health aide to perform for you
- D. It is a tool used by insurance companies to determine qualifications for medical reimbursement
Correct Answer: B
Rationale: The correct answer is B: It is a tool that is used to determine your maximum level of self-sufficiency. The purpose of a functional assessment is to evaluate a person's ability to perform daily activities independently. By determining the client's level of self-sufficiency, healthcare providers can tailor care plans to support and enhance the client's functional abilities.
Explanation of other choices:
A: Incorrect. The assessment is not about comfort but rather about assessing functional abilities.
C: Incorrect. The assessment focuses on the client's abilities, not the services they may need from a home health aide.
D: Incorrect. While assessments may impact insurance reimbursement, the primary purpose is not insurance-related but rather focused on the client's functional abilities.