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A patient is admitted with a diagnosis of renal failure. He also mentions that he has stomach distress and ha ingested numerous antacid tablets over the past 2 days. His blood pressure is 110/70, his face is flushed, and he is experiencing generalized weakness. Choose the most likely magnesium (Mg ) value.
- A. 11mEq/L
- B. 2mEq/L
- C. 5mEq/L
- D. 1mEq/L ⁺
Correct Answer: A
Rationale: The correct answer is A: 11mEq/L. In renal failure, the kidneys are unable to excrete excess magnesium, leading to hypermagnesemia. The patient's symptoms of stomach distress and ingesting antacids suggest magnesium intake. A Mg level of 11mEq/L aligns with symptoms like flushed face and weakness. Choices B, C, and D are too low for hypermagnesemia symptoms and would not explain the patient's presentation.
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Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
- A. 900 CD 4+ cells
- B. 500 CD 4+ cells
- C. 700 CD 4+ cells
- D. 200 CD 4+ cells
Correct Answer: D
Rationale: The correct answer is D: 200 CD4+ cells. In AIDS, the immune system is severely compromised, leading to a decrease in CD4+ T cells. A CD4+ count below 200 cells/mm3 is a key indicator of AIDS, as it signifies advanced immunodeficiency. Choices A, B, and C all have CD4+ cell counts above 200, which would not support the occurrence of AIDS. Therefore, the nurse would evaluate a CD4+ count of 200 cells as laboratory data that support the occurrence of AIDS.
A brain abscess is a collection of pus within the substance of the brain and is caused by:
- A. Direct invasion of the brain
- B. Spread of infection by other organs
- C. Spread infection from nearby sites
- D. All of the above mechanisms
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.
The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
- A. Citrus fruits and green leafy vegetables
- B. Bananas and nuts
- C. Coffee and tea
- D. Dairy products
Correct Answer: A
Rationale: The correct answer is A: Citrus fruits and green leafy vegetables. Citrus fruits and green leafy vegetables are good sources of Vitamin C and iron, which are essential for individuals with iron deficiency anemia. Vitamin C enhances the absorption of iron from plant-based sources, while green leafy vegetables provide iron. Bananas and nuts (choice B) are not significant sources of iron. Coffee and tea (choice C) can inhibit iron absorption. Dairy products (choice D) are not high in iron and can also inhibit iron absorption. Therefore, choosing citrus fruits and green leafy vegetables indicates understanding of the dietary instructions for managing iron deficiency anemia.
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects.
A: Having potassium levels checked is not directly related to propranolol use for hypertension management.
C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication.
D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.