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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 correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
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Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When lost hair begins to grow back
- C. When the WBC count rises to 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects.
Summary:
- Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery.
- Choice C: A high WBC count suggests potential toxicity, not readiness for treatment.
- Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.
Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR’s doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure.
Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state.
Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure.
Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
- A. Universal blood and body fluid precautions
- B. Body systems isolation
- C. Laminar flow room during active infection
- D. Needle and syringe precautions
Correct Answer: A
Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious.
Incorrect choices:
B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC.
C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV.
D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving.
A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient.
B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions.
C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.