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During the first 12 hours of hospitalization you notice that the patient's temperature, pulse, and respiration are showing a steady rise. Petechiae are developing on her chest and she is becoming confused. After notifying the physician, what is the highest priority of care?
- A. Assess for further signs of infection
- B. Continue close monitoring of vital signs and mental status
- C. Encourage fluids and reality orientation measures
- D. Increase ventilation by use of blow bottles
Correct Answer: B
Rationale: Close monitoring helps track progression and manage complications early.
You may also like to solve these questions
Which myotome is responsible for shoulder abduction
- A. C4
- B. C5
- C. C6
- D. C7
Correct Answer: B
Rationale: The C5 and C6 nerve roots innervate the deltoid and supraspinatus muscles, which are responsible for shoulder abduction. This is important in assessing brachial plexus injuries.
Which of the following instructions should be given to the client's family if a client with impaired swallowing has to take solid medication?
- A. Mix the medication with food
- B. Use the liquid form of the medication
- C. Check with the physician or pharmacist before crushing or breaking tablets
- D. or opening capsules
Correct Answer: C
Rationale: Not all medications can be safely altered, so consulting healthcare providers is essential.
Neurotransmitters carry signals across the ________ ________.
- A. refractory gap
- B. axonal gap
- C. synaptic gap
- D. hippocampal gap
Correct Answer: C
Rationale: Neurotransmitters carry signals across the synaptic gap, also known as the synaptic cleft, which is the small space between the terminal button of one neuron and the dendrite of another. When an action potential reaches the terminal button, neurotransmitters are released into the synaptic gap and bind to receptors on the postsynaptic neuron, facilitating communication between neurons. This process is essential for neural signaling and brain function.
When assessing the patient's speech, the nurse should look for:
- A. Any slurred speech or difficulty articulating words.
- B. Normal tone and rhythm of speech.
- C. Absence of speech abnormalities.
- D. Clear and coherent communication.
Correct Answer: A
Rationale: Slurred speech or difficulty articulating words may indicate neurological issues. Normal tone, absence of abnormalities, and clear communication are expected findings.
Nurse Johnson is working with Mr. Parker, who is struggling with a resting tremor in his right hand due to Parkinson's disease. Understanding how this symptom can be disruptive, Nurse Johnson offers a practical suggestion to help manage the tremor. What advice should Nurse Johnson give to Mr. Parker?
- A. Engage in deep breathing exercises.
- B. Grasp an object in his hand.
- C. Immerse in a warm bath.
- D. Use diazepam when necessary.
Correct Answer: B
Rationale: Grasping an object can help reduce the visibility and impact of resting tremors in PD patients.