Nokea
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
- A. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- B. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
- C. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Correct Answer: A
Rationale: Postural hypotension, also known as orthostatic hypotension, refers to a drop in blood pressure when a person stands up from a sitting or lying position. The usual criteria for diagnosing postural hypotension is a drop in systolic blood pressure of 20 mmHg or more or a drop in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing up.
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During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client's blood pressure
- B. An increase in the client's respiratory rate f. An increase in the client's heart rate h. A decrease in blood loss
- C. An increase in the client's respiratory rate
- D. An increase in the client's heart rate h. A decrease in blood loss
Correct Answer: A
Rationale: Placing a client in a modified Trendelenburg position involves having the client lie flat on the back with the legs elevated above the level of the heart. The main purpose of this position is to help increase blood pressure in cases of hypotension or shock. By raising the legs above the heart level, gravity helps to facilitate the return of venous blood to the heart, which can increase cardiac output and, consequently, blood pressure. This position is commonly used in clinical settings to help improve perfusion to vital organs and assist in stabilizing a client's blood pressure.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Hold the breath as the cuff is being re-inflated
- C. Take a deep breath as the nurse deflates the
- D. Exhale deeply as the nurse re-inflates the cuff cuff
Correct Answer: D
Rationale: The correct instruction for the client when removing secretions above the cuff of a tracheostomy tube is to exhale deeply as the nurse re-inflates the cuff. By having the client exhale deeply during cuff inflation, it helps to prevent aspiration of secretions or air into the lungs. This action also helps in securing an airtight seal around the tracheostomy tube before the normal breathing is resumed. It is crucial to promote the safety and prevent complications in clients with a tracheostomy tube, especially post partial laryngectomy.
The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Antibodies, also known as immunoglobulins, are proteins produced by a type of white blood cell called B-lymphocytes (B-cells). These antibodies play a crucial role in the immune response by recognizing and binding to specific antigens such as pathogens. This binding can lead to the inactivation of the pathogens or marking them for destruction by other immune cells. B-cells are a key component of the humoral immune response, which involves the production of antibodies to defend against infections. The statement that antibodies are produced by the B-cells is, therefore, true.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.
Patients with lymphoma are at risk for infection. Which of the ff. activities increases this risk?
- A. Going to church
- B. Cleaning the house
- C. Taking a walk outside
- D. Watching television
Correct Answer: C
Rationale: Patients with lymphoma are at higher risk for infections because their immune system is often compromised due to the disease itself or treatment such as chemotherapy. Going outside for a walk exposes the patient to various environmental factors including pathogens, bacteria, and viruses that can increase the risk of infections. In contrast, going to church, cleaning the house, and watching television do not necessarily pose the same level of risk for infection as being outside in the open air. It is therefore important for patients with lymphoma to avoid unnecessary exposure to potential sources of infection to reduce their risk of developing infections.