Nokea
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.
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When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction.
Incorrect choices:
B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction.
C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
- A. Smoking
- B. Heavy alcohol consumption
- C. Obesity
- D. Saccharin consumption
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a known risk factor for colon cancer as it can lead to chronic inflammation and changes in hormone levels, increasing the risk of developing cancerous cells in the colon. Smoking (choice A) is more strongly associated with lung cancer. Heavy alcohol consumption (choice B) is linked to increased risk of liver and esophageal cancer, not colon cancer. Saccharin consumption (choice D) has not been definitively linked to colon cancer. In summary, obesity is the most relevant risk factor for colon cancer among the choices provided.
The primary underlying disorder of pulmonary edema is:
- A. Decreased left ventricular pumping
- B. Increased left atrial contractility
- C. Decreased right ventricular elasticity
- D. Increased right atrial pressure
Correct Answer: A
Rationale: Step 1: Pulmonary edema is caused by fluid accumulation in the lungs due to increased pressure in the pulmonary vasculature.
Step 2: Decreased left ventricular pumping leads to congestive heart failure, causing increased pressure in pulmonary circulation.
Step 3: This increased pressure forces fluid from the capillaries into the alveoli, causing pulmonary edema.
Step 4: Increased left atrial contractility (B) would not directly lead to pulmonary edema.
Step 5: Decreased right ventricular elasticity (C) and increased right atrial pressure (D) are not directly related to the pathophysiology of pulmonary edema.
Summary: The correct answer is A because decreased left ventricular pumping directly contributes to the increased pressure in the pulmonary circulation that leads to pulmonary edema. Choices B, C, and D do not align with the primary underlying disorder of pulmonary edema.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.
A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.