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Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.
Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
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To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is necessary to prevent infection when accessing the intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field during the insertion process, reducing the risk of introducing pathogens. Using clean technique for cleansing connections (choice B) may introduce contaminants to the insertion site. Sterile technique for cleansing the insertion site (choice C) is not necessary and may be overly stringent. Closing leaks in the tubing with tape (choice D) does not address the prevention of infection at the insertion site.
Choose the condition that exhibits blood values with a low pH and a high PCO :
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metaboli₂c alkalosis
Correct Answer: A
Rationale: Correct Answer: A: Respiratory acidosis
Rationale:
1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH.
2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component.
3. Metabolic acidosis (B) results from non-respiratory causes.
4. Respiratory alkalosis (C) is characterized by high pH and low PCO₂.
5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.
. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?
- A. High corticotropin and low cortisol levels
- B. high corticotropin and high cortisol levels
- C. Low corticotropin and high cortisol levels
- D. Low corticotropin and low cortisol levels
Correct Answer: B
Rationale: Step-by-step rationale:
1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production.
2. High corticotropin levels would be expected due to the adenoma's overproduction.
3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands.
4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer.
Summary:
- Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma.
- Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma.
- Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Correct Answer: D - Lubricating eye drops
Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.
Summary of Incorrect Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.
A client reports difficulty breathing, stating, 'I can’t catch my breath.' What is the most appropriate action for the nurse to take?
- A. Validate the client’s statement by measuring oxygen saturation.
- B. Encourage the client to perform deep breathing exercises.
- C. Document the client’s statement and continue with the assessment.
- D. Provide oxygen immediately without further assessment.
Correct Answer: A
Rationale: The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.