Nokea
Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?
- A. acute viral hepatitis
- B. alcohol hepatotoxicity
- C. chronic biliary inflammation or obstruction
- D. hepatic failure with prolonged venous hepatic congestion
Correct Answer: C
Rationale: Primary biliary cirrhosis, now known as primary biliary cholangitis, is a chronic autoimmune liver disease that affects the bile ducts within the liver. The main characteristic of this condition is progressive destruction of the small bile ducts, leading to chronic biliary inflammation or obstruction. This results in the buildup of bile in the liver, causing damage and scarring (cirrhosis) over time. Factors such as acute viral hepatitis (choice A), alcohol hepatotoxicity (choice B), and hepatic failure with prolonged venous hepatic congestion (choice D) are associated with other liver conditions, but they are not specifically linked to primary biliary cholangitis.
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The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?
- A. Joint pain following administration of the medication
- B. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client
- C. A decrease in muscle strength within 30 to 60 seconds following administration of the medication.
- D. An increase in muscle strength within 30 to 60 seconds following administration of the medication
Correct Answer: D
Rationale: Edrophonium (Tensilon) is a short-acting cholinesterase inhibitor used in the Tensilon test to aid in the diagnosis of myasthenia gravis. In patients with myasthenia gravis, there is a deficiency of acetylcholine at the neuromuscular junction, leading to muscle weakness. By inhibiting the breakdown of acetylcholine, edrophonium temporarily increases the availability of acetylcholine at the neuromuscular junction.
a hospitalized child with nephrosis is receiving high doses of prednisone. which of the following is an appropriate nursing goal related to this?
- A. prevent infection.
- B. stimulate appetite.
- C. detect evidence of edema.
- D. assist in raising osmotic pressure.
Correct Answer: A
Rationale: High doses of prednisone suppress the immune system, putting the hospitalized child at an increased risk for infections. Therefore, an appropriate nursing goal related to this situation would be to prevent infection by implementing measures such as hand hygiene, maintaining a clean environment, and monitoring for signs and symptoms of infection. It is crucial to protect the child from acquiring additional illnesses while undergoing treatment for nephrosis.
Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
- A. Preload
- B. Afterload
- C. Cardiac output
- D. All of the above
Correct Answer: D
Rationale: A multilumen pulmonary artery catheter, also known as a Swan-Ganz catheter, is used for advanced hemodynamic monitoring. It is inserted through a central line and positioned in the pulmonary artery to provide detailed information about various hemodynamic parameters including preload, afterload, and cardiac output.
The primary critical observation for Apgar scoring is the:
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of the Moro reflex
Correct Answer: A
Rationale: The primary critical observation for Apgar scoring is the heart rate. This is because the heart rate is vital for life and immediate assessment of the infant's heart rate provides crucial information about the baby's overall well-being and response to the birthing process. The Apgar score assesses five components: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Among these components, the heart rate is considered the most critical because it directly reflects the infant's cardiovascular status and their ability to maintain adequate perfusion of vital organs. Therefore, for quick assessment and immediate intervention, the heart rate is prioritized as the primary observation in Apgar scoring.
A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
- A. Complete cure of the cancer
- B. Prevention of the need for oxygen
- C. Increased comfort
- D. Prevention of cancer spread
Correct Answer: C
Rationale: Radiation therapy for lung cancer is typically used with the goal of increasing comfort for the patient by reducing symptoms such as pain, shortness of breath, and coughing. While it may help to shrink tumors and slow the progression of the disease, it is usually not considered a curative treatment for advanced lung cancer. It is important for the patient to have realistic expectations and understand that the goal of radiation therapy is primarily to improve their quality of life and manage symptoms.