Nokea
One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?
- A. Meningitis
- B. Absence seizure
- C. Subdural hematoma
- D. Meniere's disease
Correct Answer: C
Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.
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The client with chronic pancreatitis should be taught how to monitor for which of the following possible additional problems associated with pancreatic disease?
- A. Hypertension
- B. Diabetes
- C. Hypothyroidism
- D. Graves' disease
Correct Answer: B
Rationale: The correct answer is diabetes. In chronic pancreatitis, the pancreas may become unable to produce sufficient insulin, leading to diabetes. This connection underscores the importance of monitoring blood sugar levels and understanding the signs and symptoms of diabetes in clients with chronic pancreatitis.
Choice A, hypertension, is not directly associated with pancreatic disease but rather with cardiovascular health. Choice C, hypothyroidism, and Choice D, Graves' disease, are unrelated to pancreatic disease and are endocrine disorders affecting the thyroid gland.
A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.
The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?
- A. 15 seconds
- B. 3 minutes
- C. 5 minutes
- D. 15 minutes
Correct Answer: B
Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.
Which factor in a client’s health history increases their risk for cancer?
- A. Family history and environment
- B. Alcohol and smoking
- C. Alcohol consumption and smoking
- D. Proximity to an electric plant and water source
Correct Answer: B
Rationale: The correct answer is 'Alcohol and smoking.' Both alcohol consumption and smoking are well-known risk factors for various types of cancer. They have a synergistic effect, meaning their combined impact raises the risk significantly. Family history and environment (Choice A) may play a role in certain cancers, but alcohol and smoking are more directly linked to increased cancer risk. Proximity to an electric plant and water source (Choice D) is not typically associated with an increased risk of cancer compared to alcohol and smoking.
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?
- A. Biot's respirations
- B. Sucking sounds during respirations
- C. Paradoxical chest wall movement
- D. Hypotension and bradycardia
Correct Answer: C
Rationale: The correct assessment finding consistent with a flail chest is paradoxical chest wall movement. This occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during respiration. Biot's respirations (Choice A) are a pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Sucking sounds during respirations (Choice B) may indicate air entering or leaving the chest cavity through a wound. Hypotension and bradycardia (Choice D) may be present due to other factors such as shock, but they are not specific to a flail chest.