Nokea
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.
You may also like to solve these questions
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
- A. “You’ll need more insulin when you exercise or increase your food intake.”
- B. “You’ll need less insulin when you exercise or reduce your food intake.”
- C. “You’ll need less insulin when you increase your intake.”
- D. “You’ll need more insulin when you exercise or decrease your food intake.”
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage. Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.
A male client recently underwent a surgical procedure for a malignant tumor. As a result of the surgery, his urine is diverted to a stomal pouch. What should the nurse suggest so that he remains odor free.
- A. Eating spicy foods
- B. Drinking cranberry juice
- C. Eating eggs, asparagus, or cheese
- D. Drinking tea, coffee and colas
Correct Answer: B
Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because:
A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor.
C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor.
D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.
Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?
- A. Mother’s who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow’s milk
- B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
- C. Females taking birth control pills are protected from getting HIV
- D. It’s okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B
Rationale: The correct answer is B. This statement shows an understanding of reducing HIV transmission by promoting harm reduction strategies like needle exchange programs, which help prevent sharing of contaminated needles. This approach is evidence-based and effective in reducing the spread of HIV among injection drug users.
Choice A is incorrect because breastfeeding by HIV-positive mothers can transmit the virus to infants. Choice C is incorrect as birth control pills do not protect against HIV, only against pregnancy. Choice D is incorrect as natural skin condoms do not provide the same level of protection against HIV as latex condoms do.
Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:
- A. High bloold pressure
- B. GIT irritation
- C. Shortness of breathing
- D. throbbing headache
Correct Answer: D
Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use.
Explanation of other choices:
A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels.
B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system.
C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.