Nokea
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.
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What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. “Avoid drinking liquids until the gag reflex returns.”
- B. “Avoid eating milk products for 24 hours.”
- C. “Notify a nurse if you experience blood in your urine.”
- D. “Remain supine for the time specified by the physician.”
Correct Answer: D
Rationale: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?
- A. Fatigue
- B. Peripheral edema
- C. Bilateral crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.
Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: B
Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
- A. Poor control of blood glucose levels
- B. Current of recent foot trauma
- C. Inappropriate foot care
- D. Advanced age
Correct Answer: D
Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual.
Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time.
Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions.
Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.