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A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?
- A. Muscle weakness
- B. Increased deep tendon reflexes
- C. Hypotension
- D. Tachycardia
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.
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A patient presents with sudden onset of weakness and numbness on one side of the body, along with difficulty speaking and understanding speech. Imaging reveals an acute infarction involving the left middle cerebral artery territory. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Transient ischemic attack (TIA)
- B. Intracerebral hemorrhage
- C. Ischemic stroke
- D. Subarachnoid hemorrhage
Correct Answer: C
Rationale: The patient is presenting with sudden onset weakness and numbness on one side of the body, along with difficulty speaking and understanding speech, which are typical symptoms of a stroke. Imaging revealing an acute infarction involving the left middle cerebral artery territory is consistent with an ischemic stroke. Ischemic stroke occurs when there is a blockage in a blood vessel supplying blood to the brain, leading to a lack of oxygen and nutrients to the affected area, resulting in neurological deficits. This is in contrast to an intracerebral hemorrhage, which is caused by bleeding into the brain tissue, or a subarachnoid hemorrhage, which involves bleeding into the space surrounding the brain. A transient ischemic attack (TIA) is a temporary episode of neurological dysfunction caused by a brief blockage of blood flow to a part of the brain, usually resolving within 24 hours. In this case, the presentation and imaging findings are most
A patient with advanced heart failure expresses fear and anxiety about the progression of their illness. What is the palliative nurse's most appropriate response?
- A. Provide reassurance and minimize discussions about end-of-life care.
- B. Encourage the patient to focus on positive thoughts and avoid discussing fears.
- C. Offer empathetic listening and explore the patient's concerns about the future.
- D. Suggest distraction techniques to divert the patient's attention from their worries.
Correct Answer: C
Rationale: The palliative nurse's most appropriate response in this scenario is to offer empathetic listening and explore the patient's concerns about the future. By providing a compassionate and supportive environment for the patient to express their fears and anxieties, the nurse can help the patient feel heard and understood. This approach allows the nurse to address the patient's emotional needs and provide appropriate support to help them cope with their feelings. Avoiding discussions or minimizing the patient's concerns may invalidate their emotions and hinder the therapeutic relationship. Encouraging distraction techniques or focusing solely on positive thoughts may not address the underlying fears and anxieties that the patient is experiencing. Therefore, offering empathetic listening and exploring the patient's concerns is the most appropriate way for the nurse to provide holistic care for the patient with advanced heart failure.
Nurse Gina has also to consider in terms of financial status most of the elderly are
- A. Sufficient
- B. disoriented
- C. Dependent to others financially
- D. Have pension
Correct Answer: C
Rationale: Nurse Gina has to consider that most of the elderly are dependent on others financially. This is an important factor to take into account when planning and providing care for elderly patients. Many elderly individuals rely on financial assistance from family members, government programs, or retirement funds. Understanding the financial status of elderly patients helps nurses like Gina provide adequate care and support to meet their needs effectively. This can involve coordinating with social services or financial assistance programs to ensure that the patients' financial concerns are addressed along with their healthcare needs.
A patient presents with fever, chills, headache, and myalgia after returning from a trip to sub-Saharan Africa. Laboratory tests reveal intraerythrocytic ring forms and trophozoites on blood smear examination. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: A
Rationale: The most likely causative agent in this scenario is Plasmodium falciparum, a protozoan parasite that causes malaria. The patient's symptoms of fever, chills, headache, and myalgia align with the typical presentation of malaria. Additionally, the presence of intraerythrocytic ring forms and trophozoites on blood smear examination is characteristic of Plasmodium species, particularly P. falciparum, which causes the most severe form of malaria.
A nurse is preparing to assist with a lumbar puncture procedure for a patient. What action should the nurse take to maintain procedural asepsis?
- A. Wearing sterile gloves and a surgical mask during the procedure
- B. Cleansing the puncture site with povidone-iodine solution
- C. Using a sterile drape to cover the patient during the procedure
- D. Avoiding unnecessary movement or talking during the procedure
Correct Answer: A
Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.