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Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?
- A. administer morphine sulfate as ordered
- B. obtain daily weights
- C. maintain Aling Loida on high calorie, high protein diet
- D. place her on supine position
Correct Answer: A
Rationale: Administering morphine sulfate as ordered would be an appropriate nursing intervention for Aling Loida who is complaining of acute abdominal pain. Morphine is a potent analgesic that can help alleviate severe pain. Pain management is crucial in acute pancreatitis to help the patient feel more comfortable and to improve their overall well-being. It is important to follow the healthcare provider's orders regarding the administration of pain medication to ensure effective pain relief for the patient.
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A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. "Anemia prevents your lungs from absorbing oxygen effectively."
- B. "You do not have enough hemoglobin to carry oxygen to your tissues."
- C. ""You don't have enough blood to feed your cells."
- D. "You have lost a lot of blood, and that has damaged your lungs."
Correct Answer: B
Rationale: The best response is option B, "You do not have enough hemoglobin to carry oxygen to your tissues." Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues throughout the body. With a low hemoglobin level of 6 g/dL due to gastrointestinal tract bleeding, there is a reduced capacity to carry oxygen to the body's tissues. This decreased oxygen-carrying capacity leads to symptoms of shortness of breath (SOB) because the body's cells are not receiving an adequate supply of oxygen. It is important to provide a clear and accurate explanation to the patient about the relationship between hemoglobin, oxygen transport, and symptoms of anemia like shortness of breath.
A nurse explains to a child's parents that the role of methotrexate (Rheumatrex®) in treating children with juvenile arthritis is to:
- A. decrease the inflammatory response.
- B. improve functional ability.
- C. control the febrile response.
- D. minimize the effects of uveitis.
Correct Answer: A
Rationale: Methotrexate, which is a disease-modifying antirheumatic drug (DMARD), is commonly used to treat juvenile arthritis by decreasing the inflammatory response in the joints. By suppressing the overactive immune response that causes inflammation in the joints, methotrexate helps reduce pain, swelling, and stiffness in children with juvenile arthritis. This ultimately helps to improve joint function and prevent joint damage. While methotrexate may indirectly contribute to improving functional ability and controlling febrile responses in some cases, its primary mechanism of action is to target and reduce inflammation in juvenile arthritis. The medication may also help in managing associated conditions like uveitis, but its main role lies in decreasing the inflammatory response in arthritis.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: A decreasing level of consciousness is a symptom often associated with increased intracranial pressure (ICP). When the pressure inside the skull rises, it can compress and damage the brain, leading to a deterioration in consciousness. Common causes of increased ICP include traumatic brain injury, brain tumors, and infections. As ICP continues to rise, it can result in serious consequences such as brain herniation, which can be life-threatening if not promptly managed. Therefore, a decreasing level of consciousness should raise concerns about increased ICP and warrant immediate medical evaluation and intervention.
Through which of the ff body fluids has transmission of HIV been established? Choose all that apply
- A. Saliva
- B. Sweat
- C. Tears f. Breastmilk
- D. Blood g. Urine
Correct Answer: C
Rationale: The transmission of HIV has been established through the following body fluids:
The nurse is teaching the parents of a child recently diagnosed with ADHD who has been prescribed methylphenidate (Ritalin). Which should the nurse include in teaching about the side effects of methylphenidate?
- A. "Your child may experience a sense of nervousness."
- B. "You may see an increase in your child's appetite."
- C. "Your child may experience daytime sleepiness."
- D. "You may see a decrease in your child's blood pressure."
Correct Answer: A
Rationale: Methylphenidate (Ritalin) is a stimulant medication commonly used in the treatment of ADHD. One of the possible side effects of methylphenidate is an increase in nervousness or jitteriness. This side effect is more common at the beginning of treatment or when the dosage is increased. It is important for parents to be aware of this potential side effect and to inform the healthcare provider if it becomes bothersome for the child. Other common side effects of methylphenidate may include decreased appetite, insomnia, and stomach upset.