Nokea
One morning during rounds, Nurse Myra noticed that Marlene was unduly sad. The nurse 's BEST way of communicating her concern is _______.
- A. whatever it is, you lift it up to God
- B. saying you are sad again, that is bad for your health
- C. telling Marlene to stop worrying, everything will be okay
- D. placing her hand over Marlene 's shoulder and asking why the sad face
Correct Answer: D
Rationale: Placing her hand over Marlene's shoulder and asking why the sad face is the best way for Nurse Myra to communicate her concern. This approach shows empathy and creates a safe space for Marlene to open up about her feelings. By using physical touch and showing genuine interest in Marlene's well-being, Nurse Myra can effectively address the situation and provide appropriate support or guidance as needed. Simply dismissing Marlene's feelings (option B and C) or resorting to religious advice (option A) may not effectively address the underlying cause of Marlene's sadness. It is important in situations like this to show empathy, compassion, and a willingness to listen in order to provide the best support for the individual in distress.
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What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
- A. Maintenance of respiratory function
- B. Prevention of decubitus
- C. Control of urinary tract infection
- D. Replacement of fluid and electrolytes
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
A woman in active labor experiences a prolonged latent phase, characterized by irregular contractions and minimal cervical dilation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Fetal malposition
- C. Maternal anxiety
- D. Fetal macrosomia
Correct Answer: A
Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.
A patient with a history of heart failure is prescribed spironolactone. Which electrolyte imbalance is the patient at risk for developing with spironolactone therapy?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.
A patient presents with gradual-onset memory loss, confusion, and difficulty with complex tasks such as managing finances and planning. Over time, the patient develops disorientation to time and place and requires assistance with activities of daily living. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Alzheimer's disease
- B. Parkinson's disease
- C. Huntington's disease
- D. Frontotemporal dementia
Correct Answer: A
Rationale: The patient's presentation of gradual-onset memory loss, confusion, difficulty with complex tasks, disorientation, and functional decline are all classic features of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disorder characterized by the accumulation of abnormal protein deposits in the brain, leading to widespread neuronal damage and cognitive decline. As the disease progresses, patients typically experience worsening memory loss, cognitive impairment, and deficits in activities of daily living, ultimately requiring full-time care and assistance. Other neurodegenerative diseases such as Parkinson's disease, Huntington's disease, and frontotemporal dementia may present with cognitive impairment and behavioral changes, but the specific constellation of symptoms described in the case is most indicative of Alzheimer's disease.