Nokea
Before administering a benzodiazepine, what should the nurse assess?
- A. Sleep problems
- B. Memory impairment
- C. Cognitive disorder
- D. Behavior changes
Correct Answer: D
Rationale: Behavioral changes may indicate underlying issues or contraindications for benzodiazepines.
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A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Decreased level of serum lipids
- C. Decreased erythrocyte sedimentation rate (ESR)
- D. Increased platelet count
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream and can cause hypocalcemia due to the formation of calcium soaps. This can lead to symptoms such as confusion and tetany. The other choices are incorrect because in FES, there is no direct impact on serum lipids or ESR. Platelet count may be normal or decreased due to the consumption of platelets in the process.
A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
- A. Confusion
- B. Weakness
- C. Increased intracranial pressure
- D. Increased urinary output
Correct Answer: B
Rationale: The correct answer is B: Weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on neuromuscular junctions. Monitoring for weakness is essential to assess disease progression and response to treatment. Confusion (A) is not a typical manifestation of myasthenia gravis. Increased intracranial pressure (C) is more commonly associated with conditions like head trauma or brain tumors. Increased urinary output (D) is not directly related to myasthenia gravis and is more indicative of conditions affecting the kidneys or fluid balance.
For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
Which quality of care measures influence the payment for health care services by third-party payers (select all that apply)?
- A. Clinical outcomes
- B. Regulatory agencies
- C. Use of evidence-based practice
- D. Occurrence of preventable conditions
Correct Answer: A
Rationale: Third-party payers prioritize clinical outcomes, evidence-based practice adoption, and minimizing preventable conditions to ensure value-based care.
Tom has Guillain-Barré syndrome and asks what causes his burning, prickling feeling. You respond by saying
- A. You are lying too long on the affected side.
- B. This is in response to your medication.
- C. The myelin cover of the nerve endings is absent.
- D. This is secondary to dysphagia.
Correct Answer: C
Rationale: Guillain-Barré syndrome damages the myelin sheath, leading to abnormal sensations.