Nokea
An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
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An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs.
- B. I see halos floating around my head.
- C. I have trouble remembering things.
- D. I have lost weight over the past month.
Correct Answer: A
Rationale: Shortness of breath, especially during exertion, is a classic symptom of heart failure due to the heart's inability to pump blood effectively.
SVT
- A. HR . 220 /min
- B. Adenosine helpful in management
- C. Beat to beat variation is not present
- D. Valsalvar maneuver is a treatment method
Correct Answer: B
Rationale: Adenosine is effective in managing supraventricular tachycardia by interrupting reentrant pathways.
The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
- A. “I should avoid tub baths but may shower.â€
- B. “I have to stay on strict bed rest for 3 days.â€
- C. “I should remove the pressure dressing the day after the procedure.â€
- D. “I may attend school but should avoid exercise for several days.â€
Correct Answer: B
Rationale: The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school.
A 3-year-old child diagnosed with congestive heart failure is receiving maintenance doses of digoxin and furosemide (Lasix). She is rubbing her eyes when she is looking at the lights in the room and her heart rate is 65 beats per minute. The nurse expects which laboratory finding?
- A. Hypokalemia
- B. Hypomagnesemia
- C. Hypocalcemia
- D. Hypophosphatemia
Correct Answer: A
Rationale: Hypokalemia is a common side effect of furosemide, a diuretic, and can exacerbate digoxin toxicity, which may present with symptoms such as visual disturbances and bradycardia.
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
- A. Pulmonary congestion
- B. Congenital heart defect
- C. Heart failure
- D. Systemic venous congestion
Correct Answer: C
Rationale: The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.