Nokea
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: A
Rationale: Toni's response of minimizing her visual problems, talking about pursuing advanced degrees, asking about full-time job opportunities in nursing, and mentioning her desire to have more children despite her current health situation may suggest inappropriate euphoria characteristic of the disease process. Inappropriate euphoria can be a sign of an altered mental state that is not in line with the reality of the situation. It is important for healthcare providers to recognize such emotional responses as they may indicate underlying mental health issues or the need for further assessment and support.
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A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: Diagnostic study findings in multiple myeloma often include the presence of Bence Jones protein in the urine. Bence Jones protein is a type of abnormal protein (immunoglobulin light chain) produced by the abnormal plasma cells in multiple myeloma. Its presence in the urine can be detected through urine protein electrophoresis and is a characteristic feature of the disease. Other common findings in multiple myeloma include hypercalcemia, elevated serum creatinine level, and high serum protein level due to the excess production of monoclonal immunoglobulins.
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: Labyrinthitis is an inner ear disorder that is often caused by a viral infection. Antihistamines are commonly used in the treatment of labyrinthitis to help reduce symptoms such as dizziness, nausea, and vomiting. Antihistamines work by blocking the effects of histamine, which is a chemical in the body that can cause these symptoms. Additionally, antihistamines can help alleviate any associated allergies or inflammation in the inner ear that may be contributing to the condition. Other treatment options for labyrinthitis may include vestibular rehabilitation exercises, antiemetics for nausea and vomiting, and medications to manage dizziness.
Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: Urinary retention in older adults with a neurologic deficit can lead to a behavior change. This change may manifest as increased restlessness, agitation, or discomfort. It is important to be vigilant for any sudden alterations in behavior as they may indicate underlying complications such as urinary retention, which can be more challenging to identify in older individuals who may have difficulty communicating their symptoms clearly. Monitoring for behavior changes can help healthcare providers promptly address and manage urinary retention in these individuals.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.