Nokea
An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?
- A. Hyponatremia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypomagnesemia
Correct Answer: A
Rationale: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Sodium plays a crucial role in regulating the body's fluid balance and is essential for nerve and muscle function. Elderly individuals are at a higher risk of developing hyponatremia due to various factors, including medication use, reduced thirst sensation, and impaired kidney function.
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Between 2-6 months of life, all are true about infant sleep EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles are shorter and differ from adult patterns.
Why are rectal temperatures not recommended in the newborn?
- A. They are inaccurate.
- B. They do not reflect core body temperature.
- C. They can cause perforation of rectal mucosa.
- D. They take too long to obtain an accurate reading.
Correct Answer: C
Rationale: Rectal temperatures are not recommended in newborns because they can potentially cause perforation of the rectal mucosa. Newborns have fragile, delicate tissues in the rectal area, and the insertion of a rectal thermometer may lead to injury or damage to the mucosal lining. It is important to exercise caution and use alternative methods for taking temperatures in newborns to avoid any harm or discomfort.
A teen asks a nurse, "What is physical dependence in substance abuse?" Which is the correct response by the nurse?
- A. Problem that occurs in conjunction with addiction
- B. Involuntary physiologic response to drug
- C. Culturally defined use of drugs for purposes other than accepted medical purposes
- D. Voluntary behavior based on psychosocial needs
Correct Answer: B
Rationale: Physical dependence in substance abuse refers to the body's physiological adaptation to a drug, leading to the development of withdrawal symptoms when the drug is abruptly stopped or reduced in dosage. This is different from addiction, which involves psychological dependence and compulsive drug-seeking behavior despite harmful consequences. Physical dependence is typically characterized by tolerance (needing higher doses to achieve the same effect) and withdrawal symptoms when the drug is stopped.
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: Decreased cardiac output is a serious concern in clients with congestive heart failure. By assessing the apical heart rate before administering digitalis, the nurse can monitor the client's cardiac status and prevent possible complications such as digitalis toxicity. Digitalis is a medication commonly used to improve cardiac output in clients with heart failure, but it can also cause harm if given inappropriately, especially if the client's heart rate is already low. Monitoring the client's apical heart rate before giving digitalis helps ensure that the medication is safely administered and that the client's cardiac status is closely monitored. This intervention is crucial in the care of clients with congestive heart failure to optimize patient safety and outcomes.
Miss OB's malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
- A. Malignant
- B. Non-malignant
- C. Benign
- D. B and C
Correct Answer: C
Rationale: A malignant tumor is characterized by its ability to spread to surrounding tissues and potentially enter the bloodstream to form secondary tumors in distant organs (metastasis). In the scenario provided, the tumor in Miss OB's left breast is described as spreading all over the surrounding and adjacent tissue but specifically noted not to be entering the bloodstream. This behavior is more indicative of a benign tumor that is growing locally but is not capable of metastasis. Therefore, the tumor is best classified as benign in this case.