Nokea
During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?
- A. Initiate isolation precautions
- B. Administer an antipyretic
- C. Draw blood cultures
- D. Prepare for lumbar puncture
Correct Answer: A
Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.
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What is the most common cause of peptic ulcers?
- A. Helicobacter pylori infection
- B. NSAID use
- C. Excessive alcohol consumption
- D. Stress
Correct Answer: A
Rationale: Helicobacter pylori infection is the most common cause of peptic ulcers. This bacterium can weaken the protective mucous coating of the stomach and duodenum, allowing acid to get through to the sensitive lining beneath. NSAID use (Choice B) can also cause peptic ulcers by disrupting the stomach's mucosal barrier. Excessive alcohol consumption (Choice C) and stress (Choice D) can exacerbate and contribute to ulcer formation but are not the primary cause.
The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following?
- A. Left ventricular atrophy.
- B. Irregular heartbeats.
- C. Peripheral vascular occlusion.
- D. Pacemaker function.
Correct Answer: A
Rationale: The correct answer is A: Left ventricular atrophy. Older adults who lead sedentary lifestyles are at risk of developing left ventricular atrophy, which can lead to decreased cardiac output during physical exertion. This condition can contribute to the client's inability to perform activities requiring physical exertion. Choice B, irregular heartbeats, may be a consideration due to the presence of a pacemaker, but the client's reported inability to perform physically exerting activities is more indicative of a structural issue like left ventricular atrophy rather than a rhythm-related problem. Peripheral vascular occlusion (Choice C) is less likely to be the cause of the client's symptoms compared to the cardiac-related issue of left ventricular atrophy. While assessing pacemaker function (Choice D) is important, the client's symptoms are more suggestive of a cardiac structural issue rather than a malfunction of the pacemaker.
Which of the following is a key symptom of hypothyroidism?
- A. Weight loss.
- B. Heat intolerance.
- C. Cold intolerance.
- D. Increased appetite.
Correct Answer: C
Rationale: Cold intolerance is a key symptom of hypothyroidism because a decreased metabolic rate leads to a reduced ability to regulate body temperature. Weight loss (Choice A) is more commonly associated with hyperthyroidism, where the metabolic rate is increased. Heat intolerance (Choice B) is also more indicative of hyperthyroidism, where excess thyroid hormone leads to an increased sensitivity to heat. Increased appetite (Choice D) is not typically seen in hypothyroidism; instead, individuals with hypothyroidism may experience weight gain due to the slowed metabolism.
In a patient with chronic obstructive pulmonary disease (COPD), which of the following interventions is most important?
- A. Encouraging the patient to stop smoking.
- B. Administering bronchodilators.
- C. Monitoring oxygen saturation.
- D. Providing nutritional support.
Correct Answer: C
Rationale: Monitoring oxygen saturation is the most important intervention in a patient with COPD because it helps assess the adequacy of oxygenation. In COPD, patients often have compromised lung function, leading to decreased oxygen levels in the blood. Monitoring oxygen saturation allows healthcare providers to promptly identify and address any potential hypoxemia, which is vital in managing COPD exacerbations. While encouraging the patient to stop smoking (Choice A) is critical for long-term management, monitoring oxygen saturation takes precedence in the immediate care of a COPD patient. Administering bronchodilators (Choice B) and providing nutritional support (Choice D) are important aspects of managing COPD but are secondary to monitoring oxygen saturation, which directly impacts the patient's oxygenation status.
Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?
- A. Liquids as desired.
- B. Small, easily digested meals.
- C. Three regular meals per day.
- D. Nothing by mouth.
Correct Answer: B
Rationale: During the acute phase of myocardial infarction, it is recommended to provide small, easily digested meals for the client. This type of diet is better tolerated as it reduces the workload on the heart, allowing for easier digestion and absorption of nutrients. Choice A, 'Liquids as desired,' may not provide adequate nutrition and may not be well-balanced. Choice C, 'Three regular meals per day,' may be too heavy for the client's weakened condition. Choice D, 'Nothing by mouth,' is not appropriate as the client still requires essential nutrients for recovery.