Nokea
An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses?
- A. Social Isolation
- B. Impaired Adjustment
- C. Defensive Coping
- D. Impaired Memory
Correct Answer: A
Rationale: Incontinence can lead to withdrawal and isolation.
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Which of the following would be considered an abnormal count for a radial pulse?
- A. 64 beats per minute
- B. 72 beats per minute
- C. 58 beats per minute
- D. 88 beats per minute
Correct Answer: C
Rationale: The correct answer is C (58 beats per minute) because a normal adult radial pulse rate typically ranges from 60-100 beats per minute. Therefore, a count of 58 would be considered below the normal range. Choices A and B fall within the normal range, while choice D is above the normal range. The abnormality in choice C warrants further investigation as it may indicate bradycardia or other underlying health conditions.
While evaluating the twelve-lead electrocardiogram tracing of your 66-year-old cardiac history patient for the possibility of an acute myocardial infarction, you note the presence of deep symmetrically inverted T waves. Which of the following is most likely the cause of this abnormal finding?
- A. Necrosis
- B. Ischemia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: B
Rationale: Rationale: Inverted T waves are typically indicative of myocardial ischemia. Ischemia leads to altered repolarization of the ventricles, causing T wave inversions. Necrosis (choice A) would manifest as pathological Q waves rather than T wave inversions. Hyperkalemia (choice C) would cause peaked T waves, not inverted T waves. Hypokalemia (choice D) could lead to U waves or flattened T waves, but not deep symmetric T wave inversions. Therefore, choice B (Ischemia) is the most likely cause based on the presented scenario and ECG findings.
Your adult patient has an altered mental status, and a blood sugar reading of 35 mg/dL is obtained using a glucometer. He is unable to follow commands, and no IV access is available. Which medication and route should be considered?
- A. Glucagon intramuscularly
- B. Oral glucose by mouth
- C. Dextrose intravenously
- D. Glucagon subcutaneously
Correct Answer: A
Rationale: The correct answer is A: Glucagon intramuscularly. Glucagon is indicated for severe hypoglycemia when the patient is unable to take oral glucose and IV access is unavailable. Administering glucagon intramuscularly will rapidly increase blood sugar levels. Oral glucose (choice B) is not suitable for a patient who cannot follow commands. Dextrose intravenously (choice C) requires IV access, which is not available in this case. Glucagon subcutaneously (choice D) may have delayed absorption compared to intramuscular administration.
A pulse oximeter measures
- A. Blood pressure
- B. Body temperature
- C. Blood oxygen level
- D. Blood glucose level
Correct Answer: C
Rationale: The correct answer is C: Blood oxygen level. A pulse oximeter measures the oxygen saturation level in the blood, indicating how well oxygen is being carried to the body's tissues. It does this by shining light through the skin to detect the amount of oxygen-bound hemoglobin in the blood. Choice A, blood pressure, is measured using a sphygmomanometer. Choice B, body temperature, is typically measured using a thermometer. Choice D, blood glucose level, is measured using a glucometer. Thus, the correct answer is C as it directly aligns with the function and purpose of a pulse oximeter.
Which of the following factors DECREASES the MAC of isoflurane?
- A. Acute cocaine intoxication
- B. Chronic ethanol abuse
- C. Symptomatic hyponatremia
- D. Hyperthyroidism
Correct Answer: C
Rationale: Symptomatic hyponatremia decreases MAC by altering neuronal excitability, reducing the anesthetic requirement for isoflurane.