A patient is scheduled for an MRI and asks what to expect. Which of the following responses by the nurse is best?
- A. “It is the measurement of muscle contraction after stimulation by tiny needle electrodes.”
- B. “Electrodes will be placed on your scalp to measure activity of the brain.”
- C. “A scan of the brain will be done after injection of radioisotope.”
- D. “It is a noninvasive test that uses magnetic energy to visualize internal parts.”
Correct Answer: D
Rationale: The correct answer is D because an MRI is a noninvasive imaging test that uses magnetic energy to produce detailed images of internal body parts. This explanation is accurate and informative, reassuring the patient.
A is incorrect because it describes electromyography (EMG), not MRI. B is incorrect as it describes electroencephalography (EEG), not MRI. C is incorrect because it describes a nuclear medicine test, not MRI. In summary, only option D provides a correct and relevant description of what to expect during an MRI.
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What is a critical component of the evaluation phase in the nursing process?
- A. Determine if client outcomes have been achieved
- B. Revise the client’s health history
- C. Establish priorities for care
- D. Formulate new nursing diagnoses
Correct Answer: A
Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved.
Step 2: Determines effectiveness of nursing interventions.
Step 3: Validates if goals are met or adjustments are needed.
Step 4: Reflects on the success of the care plan.
Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care.
Summary:
- Choice B is incorrect as revising health history is part of assessment.
- Choice C is incorrect as establishing priorities is part of the planning phase.
- Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
- A. Exposure to sunlight will help control skin rashes.
- B. There are no activity limitations between flare-ups.
- C. Monitor body temperature
- D. Corticosteroids may be stopped when symptoms are relieved.
Correct Answer: C
Rationale: Rationale:
C: Monitoring body temperature is essential for early detection of infection or fever, which can indicate disease exacerbation in SLE clients.
A: Exposure to sunlight can worsen SLE symptoms due to photosensitivity.
B: Activity limitations are crucial to prevent flare-ups and reduce disease progression in SLE.
D: Corticosteroids should not be stopped abruptly without healthcare provider guidance to prevent symptom recurrence and adrenal insufficiency.
Which of the ff. does the nurse understand are the reasons a patient with pulmonary edema is given morphine sulphate? i.To reduce anxiety iv.To increase BP ii.To relieve chest pain v.To reduce preload and afterload iii.To strengthen heart contractions
- A. 2 and 4
- B. 3 and 5
- C. 1 and 5
- D. 2 and 3
Correct Answer: C
Rationale: The correct answer is C because morphine sulfate is given to a patient with pulmonary edema to reduce anxiety (i) and to reduce preload and afterload (v). Morphine sulfate does not increase blood pressure (ii), relieve chest pain (iii), or strengthen heart contractions (iv) in the context of pulmonary edema. Choice A is incorrect because it includes increasing BP, which is not a reason for giving morphine sulfate in this case. Choice B is incorrect because it includes strengthening heart contractions, which is not a reason for administering morphine sulfate. Choice D is incorrect because it includes relieving chest pain, which is not a primary purpose of giving morphine sulfate to a patient with pulmonary edema.
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
- A. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein
- B. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein
- C. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein
- D. 55% to 60% carbohydrate, 30% fat and 10% to 15% protein
Correct Answer: C
Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.
Which of the following medications should then nurse explain may cause headache as a side effect?
- A. Furosemide (Lasix)
- B. Clonidine (Catapres)
- C. Atenolol ((Tenormin)
- D. Adalat (Procardia)
Correct Answer: B
Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.