Nokea
Mr. Reyes has a possible skull fracture. The nurse should:
- A. Observe him for signs of Brain injury
- B. Check for hemorrhaging from the oral cavity
- C. Elevate the foot of the bed if he develops symptoms of shock
- D. Observe for symptoms of decreased intracranial pressure and temperature
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
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The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: The correct answer is A: Antihistamines. Labyrinthitis is an inner ear condition often caused by inflammation or infection. Antihistamines help reduce symptoms like vertigo and dizziness by decreasing inflammation and fluid buildup in the inner ear. Anti-inflammatories (choice B) may help with inflammation but are not as effective for inner ear conditions. Antispasmotics (choice C) are not typically used for treating labyrinthitis. Antiemetics (choice D) are used to control nausea and vomiting, which can be symptoms of labyrinthitis but do not address the underlying cause.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity.
A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures.
B: Use of tilt board may not directly address the need for proper positioning to prevent contractures.
C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. In a nursing health history, the nurse focuses on understanding the patient's expectations, needs, and preferences to provide patient-centered care. This step is essential for building rapport, establishing trust, and tailoring care plans to meet the patient's individual needs.
Incorrect choices:
A: Nurse’s concerns - This is not the primary focus during a nursing health history. The nurse should prioritize understanding the patient's perspective.
C: Current treatment orders - While important, this is typically addressed during the assessment phase, not specifically in the nursing health history.
D: Nurse’s goals for the patient - The nurse's goals should align with the patient's goals, making understanding the patient's expectations crucial.