Nokea
Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:
- A. High bloold pressure
- B. GIT irritation
- C. Shortness of breathing
- D. throbbing headache
Correct Answer: D
Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use.
Explanation of other choices:
A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels.
B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system.
C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.
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Other signs of hypovolemia includes all of the following except:
- A. Dry mucous membranes and soft eyeballs
- B. Increased hematocrit and hemoglobin
- C. Decreased pulse rate and widened pulse pressure
- D. Increased lethargy and confusion
Correct Answer: C
Rationale: The correct answer is C because decreased pulse rate and widened pulse pressure are not signs of hypovolemia. In hypovolemia, the body tries to compensate by increasing the heart rate and narrowing the pulse pressure to maintain adequate blood flow. A is incorrect as dry mucous membranes and soft eyeballs are signs of dehydration. B is incorrect as increased hematocrit and hemoglobin are indicators of hemoconcentration in hypovolemia. D is incorrect as increased lethargy and confusion can be seen in severe hypovolemia due to poor perfusion of vital organs.
Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, appearance, and physical findings. It is essential for establishing a patient's baseline health status and identifying any abnormalities or changes. Reviewing literature (A) is important but not a method of data collection. Checking orders (B) is part of the assessment process but does not involve direct data collection. Ordering medications (D) is a clinical intervention and not a data collection method.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A.
1. Change in level of consciousness is crucial in assessing neurological status.
2. Tachypnea indicates possible respiratory distress or oxygenation issues.
3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion.
4. Petechiae can be a sign of bleeding disorders or sepsis.
Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms.
Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E.
Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
- A. Human Needs (Maslow) model
- B. Functional Health Patterns model
- C. Human Response Patterns model
- D. Body System model
Correct Answer: A
Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements.
Incorrect choices:
B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements.
C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements.
D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: The correct answer is C: Bacon. Bacon contains the highest kilocalorie among the given choices due to its high fat content. Fat provides 9 kilocalories per gram, while carbohydrates (like in bread and apple) provide 4 kilocalories per gram and protein (like in chicken) provides 4 kilocalories per gram. Bacon, being high in fat, has more kilocalories compared to the other choices.
Summary:
A: Apple - Low in fat, primarily consists of carbohydrates, hence lower in kilocalories.
B: Chicken - Contains protein, lower in kilocalories compared to fat, hence not the highest kilocalorie choice.
D: Bread - Mainly consists of carbohydrates, lower in kilocalories compared to fat, making it not the highest kilocalorie choice.