Nokea
A nurse reviewed the arterial blood gas reading of a 25-year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
- A. metabolic acidosis
- B. respiratory acidosis
- C. metabolic alkalosis
- D. respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is respiratory alkalosis. In respiratory alkalosis, there is an elevated pH and low carbon dioxide levels (PaCO2 < 35 mmHg). In the given arterial blood gas reading, the patient's pH is 7.41 (within normal range), PaCO2 is 29 mmHg (below normal range), indicating respiratory alkalosis. The bicarbonate level is normal (25 mEq/l), ruling out metabolic acidosis or alkalosis. The low PaO2 (54 mmHg) may indicate hypoxemia, but it is not directly related to the acid-base disorder being assessed. Metabolic acidosis (choice A) is characterized by low pH and low bicarbonate levels, which are not present in this case. Respiratory acidosis (choice B) is indicated by low pH and high PaCO2 levels, which also do not match the provided data. Metabolic alkalosis (choice C) is defined by high pH and high bicarbonate levels, which are not seen in this scenario.
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A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patient's lower extremity. Which of the following is the most probable result of the fall?
- A. Peroneal nerve injury
- B. Tibial nerve injury
- C. Sciatic nerve injury
- D. Femoral nerve injury
Correct Answer: A
Rationale: The correct answer is peroneal nerve injury. The head of the proximal fibula is in close proximity to the peroneal nerve, making it susceptible to injury when there is a fracture. The peroneal nerve runs along the fibula and can be affected by trauma to this area. Choice B, tibial nerve injury, is incorrect as the fracture site is closer to the peroneal nerve, not the tibial nerve. Choice C, sciatic nerve injury, is incorrect as the injury is more localized to the fibular head area where the peroneal nerve is affected. Choice D, femoral nerve injury, is incorrect as the femoral nerve is not immediately adjacent to the proximal fibula and is not typically affected by this type of injury.
A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.
A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?
- A. The patient may be developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).
When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. cool, clammy skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. "You can eat anything you want, but avoid foods with sugar."?
- B. "You need to lose weight, so your diet must be controlled."?
- C. "You need a diet and exercise program."?
- D. "You must reduce salt, fat, and sugar intake in your diet."?
Correct Answer: C
Rationale: A client newly diagnosed with Diabetes Mellitus requires education on managing their condition. Choice C is the correct answer because it emphasizes the importance of a comprehensive approach involving both diet and exercise. This holistic approach is crucial in managing blood sugar levels and overall health for individuals with diabetes. Choice A is incorrect as it provides misleading information by suggesting that the client can eat anything as long as it doesn't contain sugar, which is not accurate for diabetes management. Choice B is not the best option as it focuses solely on weight loss rather than addressing the holistic needs of a diabetic individual. Choice D is incorrect as it suggests eliminating all salt, fat, and sugar, which is an extreme approach and not a realistic or balanced way to manage diabetes.