Nokea
In teaching a female client who is HIV positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- A. “The baby can get the virus from my placenta.”
- B. “I’m planning on starting on birth control pills.”
- C. “Not everyone who has the virus gives birth to a baby who has the virus.”
- D. “I’ll need to have a C-section if I become pregnant and have a baby.”
Correct Answer: B
Rationale: The correct answer is B because starting birth control pills does not protect against HIV transmission to the baby during pregnancy. The other choices demonstrate understanding of HIV transmission risks and prevention methods. A shows awareness of vertical transmission, C recognizes that not all babies born to HIV-positive mothers are infected, and D acknowledges the potential need for a C-section to reduce transmission risk. Starting birth control pills is unrelated to preventing mother-to-child HIV transmission during pregnancy.
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Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
- A. Insomnia
- B. Agnosia
- C. Aphraxia
- D. Aphasia
Correct Answer: D
Rationale: The correct answer is D: Aphasia. Aphasia is a language disorder that affects a person's ability to communicate and understand speech. In this case, Mr. Dela Isla's difficulty in comprehending what the nurse was saying indicates a problem with language processing, which aligns with the symptoms of aphasia. Insomnia (A) is a sleep disorder, not related to language comprehension. Agnosia (B) is a perception disorder where someone cannot recognize objects or people, not related to language. Apraxia (C) is a motor disorder affecting the ability to perform purposeful movements, not related to language comprehension.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.
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: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis caused by Neostigmine. Edrophonium HCL is a fast-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis. If the patient's weakness improves after administration of edrophonium, it indicates that the weakness was due to myasthenia gravis and not cholinergic crisis caused by excessive neostigmine. Choice A is incorrect because there is no synergestic effect between neostigmine and edrophonium. Choice B is incorrect as resistance to neostigmine is not a valid reason for ordering edrophonium. Choice D is incorrect because edrophonium is used for differential diagnosis, not for confirming the diagnosis of myasthenia gravis.
Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
- A. Urinary output
- B. Serum ammonia level
- C. Abdominal girth
- D. Hepatic encephalopathy
Correct Answer: C
Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.