Herpes zoster is caused by the varicella virus and has an affinity for:
- A. sympathetic nerve fibers.
- B. parasympathetic nerve fibers.
- C. posterior root ganglia and posterior horn of the spinal cord.
- D. lateral and dorsal columns of the spinal cord.
Correct Answer: C
Rationale: Herpes zoster, commonly known as shingles, is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. This virus has an affinity for sensory nerve fibers, particularly those located in the posterior root ganglia and the posterior horn of the spinal cord. When the virus becomes reactivated, it travels along these nerves to the skin, leading to the characteristic painful rash and blisters that are seen in herpes zoster. The involvement of these specific nerve fibers explains the typical dermatomal distribution of the rash in shingles.
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What is an important consideration regarding TPN administration?
- A. IV site is kept aseptic while infusing the solution
- B. Feeding is poured into a pouch and then infused
- C. Solution is only hung for a maximum of 8 hours at a time New formula is added as needed so the line does not run dry
- D. Solution is only hung for a maximum of 8 hours at a time h. New formula is added as needed so the line does not run dry
Correct Answer: A
Rationale: An important consideration regarding TPN administration is ensuring the intravenous (IV) site is kept aseptic while infusing the solution. This is crucial to prevent the risk of infection, as TPN solutions are highly concentrated and can provide an ideal environment for the growth of microorganisms. Strict aseptic technique must be maintained during the entire process of TPN administration, from preparation to infusion, to minimize the risk of introducing pathogens into the patient's system. Failure to maintain aseptic technique can lead to serious complications such as bloodstream infections, which can be life-threatening for the patient.
A 27-year old adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nutritional health?
- A. Anthropometric measurements
- B. dry skin
- C. bleeding gums
- D. facialrubor
Correct Answer: A
Rationale: Anthropometric measurements, such as height, weight, body mass index (BMI), and waist circumference, are essential in assessing the nutritional health of a patient with Crohn's disease. These measurements provide objective data about the patient's nutritional status, body composition, and risk for malnutrition. Monitoring changes in these measurements over time can help identify nutritional deficiencies, weight loss, or malnutrition in patients with Crohn's disease. Dry skin, bleeding gums, and facial rubor can be symptoms of other health conditions, but anthropometric measurements directly assess the nutritional health of the patient.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. If a client with SIADH does not comply with the recommended treatment of diuretic therapy and fluid/sodium restriction, there will be continued water retention, resulting in further dilution of sodium levels in the blood (hyponatremia). Severe hyponatremia can lead to cerebral edema, which is a life-threatening complication associated with neurological symptoms such as headache, confusion, seizures, and potentially coma. Therefore, it is important for the client to follow the prescribed treatment to prevent the development of cerebral edema and other serious complications.
The MOST common type of cerebral palsy is
- A. ataxic cerebral palsy
- B. spastic cerebral palsy
- C. dystonic cerebral palsy
- D. dyskinetic cerebral palsy
Correct Answer: B
Rationale: Spastic cerebral palsy is the most common type.
A client has the following blood lab values: platelets 50,000/ul, RBC's 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
- A. Bleeding precautions
- B. Isolation to prevent infection
- C. Seizure precautions
- D. Control of pain with analgesics
Correct Answer: A
Rationale: The client's platelet count of 50,000/ul is significantly low (normal range is around 150,000-450,000/ul). A low platelet count places the client at risk for bleeding tendencies. Therefore, the most appropriate nursing instruction to include in the teaching plan is bleeding precautions. This would involve educating the client on measures to prevent bleeding such as avoiding activities that may cause injury, using a soft toothbrush, avoiding tight clothing, and being cautious while shaving.