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Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
- A. bradycardia, weight loss, heart failure, diarrhea
- B. tachycardia, constipation, exopthalmus
- C. lethargy, weight gain, slow speech, decreased RR
- D. hypothermia, weight loss, increased RR
Correct Answer: C
Rationale: The symptoms of myxedema, which is a severe form of hypothyroidism, include lethargy, weight gain, slow speech, and decreased respiratory rate. Aling Maria being a 58-year old female who was admitted for the third time because of myxedema would likely present with these symptoms upon assessment by Nurse Mida. Other common symptoms of myxedema include cold intolerance, dry skin, hair loss, and brittle nails. It is important for Nurse Mida to identify these symptoms during the initial assessment to provide appropriate care and management for Aling Maria.
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A nurse is interviewing the parents of a toddler about use of complementary or alternative medical practices. The parents share several practices they use in their household. Which should the nurse document as complementary or alternative medical practices? (Select all that apply.)
- A. Use of acetaminophen (Tylenol) for fever
- B. Administration of chamomile tea at bedtime
- C. Hypnotherapy for relief of pain
- D. Acupressure to relieve headaches
Correct Answer: B
Rationale: Administration of chamomile tea at bedtime is considered a complementary medical practice, as it involves the use of an herb for its potential therapeutic effects.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: B
Rationale: - **Encourage a liberal fluid intake (B):** It is essential to maintain hydration after a lumbar puncture to help prevent or alleviate a headache, which may occur due to a decrease in cerebrospinal fluid (CSF) pressure. Adequate hydration can help reduce the chances of a post-lumbar puncture headache.
A 1-year-old child develops right eye ptosis, miosis, and loss of sweating; you suspect neuroblastoma. The MOST valuable investigation to confirm the diagnosis is
- A. CT scan of the neck and chest
- B. CT scan of the abdomen
- C. CT scan of the brain
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: A
Rationale: CT scan of the neck and chest can help identify a primary neuroblastoma mass in the adrenal gland or sympathetic chain.
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: B
Rationale: Osmosis is the process by which water moves across a semi-permeable membrane to equalize concentrations on both sides of the membrane. When albumin is administered intravenously, it creates an osmotic pressure in the bloodstream that draws water from the interstitial space into the blood vessels. This shift of body fluids associated with the intravenous administration of albumin occurs through the process of osmosis.
A classic full blown AIDS case is identified by clinical manifestations such as:
- A. Persistent generalized lymphadenopathy
- B. Sudden loss of weight, afternoon fever and general malaise
- C. Tumors and opportunistic infections
- D. Fever, weight loss, night sweats and diarrhea
Correct Answer: C
Rationale: A classic full-blown AIDS case is characterized by the presence of tumors and opportunistic infections due to the severe immunodeficiency caused by the human immunodeficiency virus (HIV). As the immune system becomes progressively weakened, the individual becomes highly susceptible to various infections and malignancies, which are typically not seen in individuals with a healthy immune system. The presence of tumors and opportunistic infections in an individual signifies the advanced stage of HIV infection and the progression to AIDS. The other options (A, B, D) are more general symptoms that can be seen in various stages of HIV infection and are not specific to a full-blown AIDS case.