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Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: The correct answer is B: canned tomato juice. Canned tomato juice is high in sodium content, which would not be suitable for a patient on a 2 gm sodium diet for heart failure. Sodium restriction is crucial in managing heart failure to reduce fluid retention and strain on the heart. Whole wheat bread, beef tenderloin strips, and apples are lower in sodium content compared to canned tomato juice, making them more appropriate choices for someone on a low-sodium diet.
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The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
- A. Renal calculi
- B. Delayed ejaculation
- C. Hematuria
- D. Impotence
Correct Answer: C
Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly.
Other choices are incorrect:
A: Renal calculi - BCG therapy is not known to cause renal calculi.
B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation.
D: Impotence - BCG therapy is not linked to impotence.
A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"
- A. "Have you been exposed recently to anyone with an infection?"
- B. "When did you first notice that your temperature had gone up?"
Correct Answer: A
Rationale: Rationale:
- The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms.
- Choice B is irrelevant as the client's current sore throat is not the main concern.
- Choice C and D do not address the potential infectious etiology of the symptoms.
- Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.
Morphine is given in acute pulmonary edema to redistribute the pulmonary circulation to the periphery by decreasing:
- A. Periphery resistance
- B. Pulmonary capillary pressure
- C. Transudation of fluid
- D. All of the above CARING FOR CLIENTS WITH HEART FAILURE
Correct Answer: D
Rationale: The correct answer is D because morphine helps in acute pulmonary edema by decreasing peripheral resistance, pulmonary capillary pressure, and transudation of fluid. Morphine causes vasodilation, reducing peripheral resistance, which helps redistribute blood flow to the periphery. It also reduces pulmonary capillary pressure by decreasing preload and afterload, leading to decreased fluid transudation into the alveoli. Choices A, B, and C individually do not cover all the effects of morphine in acute pulmonary edema, making them incorrect.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.