Nokea
An adult is on long term aspirin therapy and is experiencing tinnitus. What is the best interpretation of this occurrence?
- A. The aspirin is working correctly
- B. The client has an upper GI bleed
- C. The client has a metal taste in their mouth
- D. The client is experiencing a mild overdosage
Correct Answer: D
Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.
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Which of the following is the most critical intervention needed for a client with myxedema coma?
- A. Administering an oral dose of levothyroxine (Synthroid)
- B. Warming the client with a warming blanket
- C. Measuring and recording accurate intake and output
- D. Maintaining a patent airway
Correct Answer: A
Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.
One of the side effects of INH administration is peripheral neuropathy. To prevent this effect, Nurse Carlos teaches Andrew to:
- A. have a strict low cholesterol diet
- B. get extra bed rest
- C. supplement the diet with pyridoxine
- D. avoid excessive sun exposure
Correct Answer: C
Rationale: Step-by-step rationale:
1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency.
2. Pyridoxine is vitamin B6, which helps prevent neuropathy.
3. Supplementing with pyridoxine can counteract the deficiency caused by INH.
4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice.
Summary:
- Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency.
- Option B is incorrect as excessive bed rest does not prevent neuropathy.
- Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
- A. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests
- B. Advanced medical interventions can cure most autoimmune disorders
- C. Autoimmune disorders include connective tissue (collagen) disorders
- D. Autoimmune disorders are distinctive, adding differential diagnosis
Correct Answer: C
Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders.
Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body.
Summary of other choices:
A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide.
B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading.
D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.
Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
- A. Hang it on the top of the wheelchair backrest.
- B. Place it on the patient’s feet and ask the patient to hold it.
- C. Hang it on the same pole as the patient’s IV.
- D. Place it in the patient’s lap.
Correct Answer: A
Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.
Which of the ff nursing interventions ensure that a client with Hodgkin’s disease remains free of infection? Choose all that apply
- A. Apply ice to the skin for brief periods
- B. Provide cool sponge baths
- C. Practice conscientious hand washing
- D. Use cotton gloves Restrict visitors or personnel with infections from contact with the client
Correct Answer: C
Rationale: Rationale:
C: Practice conscientious hand washing is correct as it helps prevent the spread of infection. Proper hand hygiene is essential in reducing the risk of infection transmission to the client with Hodgkin's disease.
A: Apply ice to the skin for brief periods is incorrect as it does not directly relate to preventing infection in the client.
B: Provide cool sponge baths is incorrect as it mainly addresses comfort and hygiene but does not specifically target infection prevention.
D: Use cotton gloves Restrict visitors or personnel with infections from contact with the client is incorrect because while using gloves can help prevent the spread of infection, restricting visitors with infections is not under the direct control of the nurse.
Summary:
Practicing conscientious hand washing is crucial in preventing infection in a client with Hodgkin's disease, while the other choices do not directly address infection control in this context.