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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 right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.
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Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.
Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue.
A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty.
B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition.
C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem.
In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
To monitor the severity of a patient’s heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?
- A. Weight
- B. Appetite
- C. Calorie count
- D. Abdominal girth
Correct Answer: A
Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities.
Incorrect choices:
B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders.
C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders.
D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.
Choose the condition that exhibits blood values with a low pH and a high PCO :
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metaboli₂c alkalosis
Correct Answer: A
Rationale: Correct Answer: A: Respiratory acidosis
Rationale:
1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH.
2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component.
3. Metabolic acidosis (B) results from non-respiratory causes.
4. Respiratory alkalosis (C) is characterized by high pH and low PCO₂.
5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.