Nokea
In an individual with Sjogren’s syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.
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. A client is prescribed prednisone (Deltasone) daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
- A. Taking the drug at the same time every day establishes a regular routine, reducing the risk of forgetting a dose.
- B. Prednisone has a longer half-life with morning administration, making it more effective.
- C. Morning administration of prednisone mimics the body’s natural corticosteroid secretion pattern.
- D. Prednisone is best absorbed when taken on an empty stomach first thing in the morning.
Correct Answer: C
Rationale: The correct answer is C because morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Cortisol, a natural corticosteroid, is typically highest in the morning and decreases throughout the day. By taking prednisone in the morning, the client aligns the drug's peak concentration with the body's natural cortisol levels, optimizing its therapeutic effects.
Choice A is incorrect because while taking the drug at the same time daily is important for consistency, it does not specifically address the rationale for morning administration. Choice B is incorrect as the effectiveness of prednisone is not solely dependent on its half-life but also on alignment with the body's natural rhythm. Choice D is also incorrect as prednisone can be taken with food and does not necessarily require an empty stomach for optimal absorption.
Mr. Garcia, a 41-year old chronic alcohol drinker is admitted to the hospital after vomiting bright red blood. He was diagnosed to have a bleeding gastric ulcer and suddenly develops sudden sharp pain in the midepigastric region with a rigid boardlike abdomen. This likely indicates:
- A. development of intestinal
- B. inflammation of the esophagus
- C. perforation of the ulcer
- D. development of additional ulcers
Correct Answer: C
Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
A client has been scheduled for a Schilling test. What instruction will the nurse give the client?
- A. Take nothing mouth fro 12 hours prior to the test
- B. Collect his urine for 12 hours
- C. Administer a fleet enema the evening before the test
- D. Empty his bladder immediately before the test
Correct Answer: B
Rationale: The correct answer is B: Collect his urine for 12 hours. This instruction is given because the Schilling test involves collecting urine over a specific time period to measure the absorption of vitamin B12. A is incorrect because fasting is not necessary. C is incorrect as enema is not required. D is incorrect as emptying the bladder is not part of the test procedure.