Nokea
Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR’s doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure.
Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state.
Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure.
Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B, "What reasons do you think are contributing to your fatigue?" This question encourages the patient to explore and express their own thoughts and feelings, leading to a more detailed and comprehensive understanding of the underlying causes of their daytime fatigue.
A: "Is there anything that you are stressed about right now that I should know?" - This question is more direct and may not necessarily prompt the patient to delve into the specific reasons for their fatigue.
C: "What are your normal work hours?" - While relevant, this question focuses solely on work hours and may not uncover other potential factors contributing to the fatigue.
D: "Are you sleeping 8 hours a night?" - While sleep is important, this question is too narrow and may not address other possible reasons for the fatigue.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Mammography
- C. Fine needle aspiration
- D. Chest x-ray
Correct Answer: C
Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?
- A. Call the doctor
- B. Maintain the antibiotic
- C. Call for help
- D. Turn off the antibiotic
Correct Answer: D
Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
- A. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein
- B. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein
- C. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein
- D. 55% to 60% carbohydrate, 30% fat and 10% to 15% protein
Correct Answer: C
Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.