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A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?
- A. Respiratory depression
- B. Urticaria and pruritus
- C. Hypertension
- D. Decreased uterine contractility
Correct Answer: B
Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.
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A patient presents with gradual-onset memory loss, confusion, and difficulty with complex tasks such as managing finances and planning. Over time, the patient develops disorientation to time and place and requires assistance with activities of daily living. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Alzheimer's disease
- B. Parkinson's disease
- C. Huntington's disease
- D. Frontotemporal dementia
Correct Answer: A
Rationale: The patient's presentation of gradual-onset memory loss, confusion, difficulty with complex tasks, disorientation, and functional decline are all classic features of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disorder characterized by the accumulation of abnormal protein deposits in the brain, leading to widespread neuronal damage and cognitive decline. As the disease progresses, patients typically experience worsening memory loss, cognitive impairment, and deficits in activities of daily living, ultimately requiring full-time care and assistance. Other neurodegenerative diseases such as Parkinson's disease, Huntington's disease, and frontotemporal dementia may present with cognitive impairment and behavioral changes, but the specific constellation of symptoms described in the case is most indicative of Alzheimer's disease.
A patient is prescribed an opioid analgesic for the management of acute pain. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypertension
- B. Hypoglycemia
- C. Respiratory depression
- D. Hyperkalemia
Correct Answer: C
Rationale: Opioid analgesics are known to suppress the respiratory centers in the brain, leading to respiratory depression as a side effect. This adverse effect is particularly dangerous and potentially life-threatening, especially in patients who are opioid-naive or when high doses are administered. Therefore, it is crucial for the nurse to closely monitor the patient's respiratory rate, depth, and effort while on opioid analgesic therapy to detect early signs of respiratory depression and intervene promptly to prevent complications. Hypertension, hypoglycemia, and hyperkalemia are not commonly associated with opioid analgesics.
Which of the following interventions is most appropriate for managing a patient with acute respiratory failure and hypercapnia due to chronic obstructive pulmonary disease (COPD) exacerbation?
- A. Administration of supplemental oxygen via non-rebreather mask
- B. Initiation of non-invasive positive pressure ventilation (NIPPV)
- C. Placement of an indwelling arterial catheter for continuous monitoring
- D. Titration of inhaled bronchodilators and corticosteroids
Correct Answer: B
Rationale: In a patient with acute respiratory failure and hypercapnia due to a COPD exacerbation, the most appropriate intervention is the initiation of non-invasive positive pressure ventilation (NIPPV). NIPPV helps improve ventilation and oxygenation by providing mechanical support to the patient's breathing without the need for endotracheal intubation. It can reduce the work of breathing, decrease carbon dioxide retention, and improve respiratory muscle function. This intervention is particularly beneficial for COPD exacerbations as it can help alleviate hypercapnia and hypoxemia, leading to improved outcomes and potentially reducing the need for invasive ventilation methods. Therefore, NIPPV is the recommended management strategy in this scenario.
Which of the following nursing measures would the nurse LEAST CONSIDERS to Patient Ellie with oxytocin drip?
- A. Know, how to recognize potential adverse reactions:
- B. Administer oxytocin drug with caution
- C. Monitor patient closely when infusing oxytocin
- D. Inform patient about potential complications.
Correct Answer: D
Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.
A client has undergone a lymph node biopsy. The nurse anticipates that the report will reveal which result if the client has Hodgkin's Lymphoma?
- A. Reed-Sternberg cells
- B. Philadelphia chromosome
- C. Epstein-barr virus
- D. Herpes simplex virus
Correct Answer: A
Rationale: Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of Hodgkin's Lymphoma. They are typically found in the affected lymph nodes of individuals with Hodgkin's Lymphoma when examined under a microscope. Identifying Reed-Sternberg cells in a lymph node biopsy is a key diagnostic feature of Hodgkin's Lymphoma. This distinguishes Hodgkin's Lymphoma from other types of lymphomas that do not have Reed-Sternberg cells.