Nokea
A patient complains of tingling in his fingers. He has positive Trousseau’s and Chvostek’s signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
- A. 11mg/dl
- B. 7mg/dl
- C. 9mg/dl ⁺
- D. 5mg/dl
Correct Answer: A
Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels. Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.
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A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
- A. Comprehensive
- B. Focused
- C. Time-lapsed
- D. Emergency
Correct Answer: C
Rationale: The correct answer is C: Time-lapsed assessment. This type of assessment involves comparing baseline data with new data collected at a later time to evaluate changes in the client's condition. In this scenario, the nurse is reassessing the client a month later to determine if there have been any changes that require adjustments to the care plan.
A: Comprehensive assessment is an in-depth assessment done initially to gather detailed information about the client's overall health status.
B: Focused assessment is done to gather specific information related to a particular problem or issue.
D: Emergency assessment is performed in urgent situations to quickly identify and address life-threatening conditions.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
- A. To prevent confusion
- B. To prevent cerebrospinal fluid (CSF)
- C. To prevent seizures leakage
- D. To prevent cardiac arrhythmias
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage.
Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache.
Incorrect choices:
A: To prevent confusion - Irrelevant to the procedure.
C: To prevent seizures leakage - Seizures are not a concern with spinal blocks.
D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.
The nurse knows that Parkinson’s disease a progressive neurologic disorder is characterized by:
- A. Bradykinesia
- B. Tremor
- C. Muscle rigidity
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today’s dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The correct answer is A because observing the patient for abnormal bleeding is an appropriate action to monitor for potential complications of warfarin therapy. This aligns with the nursing role in assessing and monitoring patient responses to treatment.
B is incorrect as increasing warfarin dose without physician order can lead to adverse effects. C is incorrect as altering the dose without medical advice can be dangerous. D is incorrect as administering Vitamin K would counteract the effects of warfarin, which is used to prevent blood clotting.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
- A. The client’s chemotherapy causes him nausea and loss of appetite.
- B. The client became teary when his daughter from out of state came to the bedside.
- C. The client’s ileostomy put out 125 mL of effluent in the past four hours.
- D. The patient is unwilling to manipulate or empty his ostomy bag.
Correct Answer: A
Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception.
Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.