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If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
- A. Expressive aphasia is prominent on clients with right sided weakness
- B. The affected lobe in the patient is the Right lobe
- C. The client will have problems in judging distance and proprioception
- D. Clients orientation to time and space will be much affected NEUROLOGIC NURSING Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.
Correct Answer: B
Rationale: The correct answer is B because the right side weakness indicates a lesion in the left hemisphere of the brain. The brain's motor functions are contralaterally controlled, meaning the left hemisphere controls the right side of the body. Therefore, a right-sided weakness suggests a lesion in the left hemisphere. The other choices are incorrect because expressive aphasia is associated with left hemisphere lesions, judgment of distance and proprioception are more related to parietal lobe lesions, and orientation to time and space is not directly linked to right-sided weakness.
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During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. This is a common AIDS-related cancer caused by Human Herpesvirus 8 (HHV-8) in immunosuppressed individuals. It presents as purplish lesions on the skin and mucous membranes. Squamous cell carcinoma (A) is not specific to AIDS. Leukemia (B) and Multiple myeloma (C) are not commonly associated with AIDS. Kaposi’s sarcoma is the hallmark cancer seen in AIDS patients due to their weakened immune system.
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
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves verifying the accuracy and consistency of data by comparing it with other reliable sources. This ensures that the data is correct and reliable for analysis. Choice A is incorrect because data validation typically occurs after data collection, which is followed by data interpretation. Choice B is incorrect because validation is not about professional standards but about verifying data accuracy. Choice D is incorrect because data interpretation focuses on deriving meaning and insights from data, not on professional standards. In summary, understanding the differences between data validation and interpretation is crucial for ensuring data accuracy and reliability.
Which of the ff is the most important factor in the nursing management of a client with CFS?
- A. Teaching the client how to avoid aggravating the disease
- B. Informing the client about the drug therapy that will provide significant improvement
- C. Advising the client to alter the diet and environment
- D. Educating the client about the disease process and its limitations
Correct Answer: D
Rationale: The correct answer is D because educating the client about the disease process and its limitations is crucial in managing Chronic Fatigue Syndrome (CFS). By understanding the disease, the client can make informed decisions regarding their lifestyle, activities, and self-care. This empowers the client to manage symptoms effectively and prevent exacerbations.
Choice A is not the most important factor as simply avoiding aggravating the disease does not address the overall management of CFS.
Choice B focuses solely on drug therapy, which is only one aspect of the client's management and may not provide significant improvement for all clients with CFS.
Choice C, altering diet and environment, can be helpful but may not be the most important factor as understanding the disease process and limitations is essential for long-term management and quality of life.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- B. Carcinoma is situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
- D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer: B
Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed.
Step 2: N0 indicates no abnormal regional lymph nodes are involved.
Step 3: M0 signifies no evidence of distant metastasis.
Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report.
Summary:
A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor.
C: Incorrect - TIS already assesses tumor presence, ruling out this option.
D: Incorrect - TIS is not about ascending degrees of distant metastasis.