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A patient is diagnosed as having elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what?
- A. Platelets and fibrin.
- B. Fatty streaks.
- C. White blood cells (WBC).
- D. Foam cells.
Correct Answer: B
Rationale: The correct answer is B: Fatty streaks. Fatty streaks are the earliest visible signs of atherosclerosis and are primarily composed of lipid-laden macrophages within the arterial wall. Platelets and fibrin (A) are involved in clot formation, not the initial stages of plaque formation. White blood cells (C) and foam cells (D) are involved in the later stages of atherosclerosis. The other choices are irrelevant to the initial development of plaque.
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The nurse evaluates the effects of warfarin by monitoring what lab test?
- A. Platelet count.
- B. Activated thromboplastin time (APT).
- C. Red blood count (RBC).
- D. Prothrombin time (PT) and international normalized ratio (INR).
Correct Answer: D
Rationale: The correct answer is D: Prothrombin time (PT) and international normalized ratio (INR). Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Monitoring PT and INR levels helps assess the effectiveness and safety of warfarin therapy. PT measures the time it takes for blood to clot, while INR standardizes PT results. Platelet count (A) assesses clot formation ability, not warfarin effects. APT (B) primarily evaluates the intrinsic pathway of coagulation. RBC count (C) measures oxygen-carrying capacity, unrelated to warfarin effects.
A patient who experiences motion sickness when flying asks the nurse the best time to take the medication prescribed to prevent motion sickness for a flight. The nurse will instruct the patient to take the medication at what time?
- A. As needed at the first sign of nausea.
- B. When seated just prior to takeoff.
- C. At 0830 just prior to boarding the flight.
- D. At 0700 before leaving for the airport.
Correct Answer: D
Rationale: The correct answer is D: At 0700 before leaving for the airport. Taking the medication at 0700 allows for sufficient time for the medication to be absorbed and reach peak effectiveness before the flight. This timing ensures that the patient is protected from motion sickness throughout the entire duration of the flight. Choice A is not ideal as waiting until the first sign of nausea may lead to inadequate prevention. Choices B and C do not provide ample time for the medication to take effect before flight.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.
A student asks the pharmacology instructor to explain the action of anticholinergic agents. What would be the instructor's best response?
- A. They compete with serotonin for muscarinic acetylcholine receptor sites.
- B. They increase norepinephrine at the neuromuscular junction.
- C. They block nicotinic receptors.
- D. They act to block the effects of the parasympathetic nervous system.
Correct Answer: D
Rationale: The correct answer is D: They act to block the effects of the parasympathetic nervous system. Anticholinergic agents inhibit the action of acetylcholine, the primary neurotransmitter of the parasympathetic nervous system. By blocking muscarinic acetylcholine receptors, these agents reduce parasympathetic stimulation, leading to effects such as decreased salivation, decreased GI motility, and pupil dilation.
Choice A is incorrect because anticholinergic agents do not compete with serotonin for receptor sites; they primarily target acetylcholine receptors. Choice B is incorrect as anticholinergic agents do not directly affect norepinephrine levels at the neuromuscular junction. Choice C is incorrect because anticholinergic agents primarily target muscarinic receptors, not nicotinic receptors.
A patient diagnosed with Heart Failure would like the nurse to explain what the diagnosis means. How will the nurse explain heart failure?
- A. The heart muscle cannot pump effectively, causing a backup of blood.
- B. Increased protein leads to reduced oncotic pressure and inability to pull the fluid into the system.
- C. The hydrostatic pressure pushing fluids out of the capillary is lower than the oncotic pressure.
- D. The decrease in venous pressure from the backup of blood increases hydrostatic pressure.
Correct Answer: A
Rationale: The correct answer is A: The heart muscle cannot pump effectively, causing a backup of blood. This is the most accurate explanation of heart failure. In heart failure, the heart is unable to pump blood efficiently, leading to a backup of blood in the circulatory system. This can result in symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation for why the other choices are incorrect:
B: Increased protein leading to reduced oncotic pressure is not a direct cause of heart failure.
C: This choice describes the forces involved in fluid movement, not the primary mechanism of heart failure.
D: Heart failure causes a backup of blood, which in turn increases venous pressure, not the other way around.
In summary, choice A is correct as it directly addresses the primary issue of heart failure, while the other choices focus on different physiological processes not directly related to heart failure.