Nokea
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
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Which of the ff symptoms is associated with AIDS related distal sensory polyneuropathy (DSP)?
- A. Staggering gait and muscle incoordination
- B. Abnormal sensations such as burning and numbness
- C. Delusional thinking
- D. Incontinence
Correct Answer: B
Rationale: The correct answer is B: Abnormal sensations such as burning and numbness. In AIDS-related DSP, damage to nerves causes abnormal sensations like burning and numbness. This is due to the progressive nerve damage affecting sensory functions. Staggering gait and muscle incoordination (A) are more common in conditions affecting motor nerves. Delusional thinking (C) is not a symptom of DSP. Incontinence (D) is not typically associated with DSP but may happen in more advanced stages due to loss of sensation.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.
Antibodies are made of which of the following types of substances?
- A. Fat
- B. Protein
- C. Sugar
- D. Carbohydrates CARE OF PATIENTS WITH IMMUNE DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Protein. Antibodies are a type of protein produced by the immune system to help identify and neutralize pathogens like bacteria and viruses. Proteins are composed of amino acids, which are the building blocks of proteins. Antibodies have a specific structure that allows them to bind to specific antigens. Fat (A), Sugar (C), and Carbohydrates (D) are not primary components of antibodies and do not play a significant role in their structure or function.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows:
1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management.
2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery.
3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life.
4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
- A. Epinephrine
- B. 50% dextrose
- C. Glucagon
- D. Hydrocortisone
Correct Answer: C
Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.