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The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: The correct answer is B: Direct bilirubin level of 2 mg/dl. Acetaminophen toxicity can lead to liver damage, causing an increase in bilirubin levels. Direct bilirubin specifically indicates liver function. A: Sodium level is not related to acetaminophen toxicity. C: Prothrombin time is a measure of blood clotting, not indicative of acetaminophen toxicity. D: Platelet count is not affected by acetaminophen toxicity.
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After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Choice C:
1. Safety First: Recording vital signs is crucial for patient safety. Asking the NAP to record vital signs ensures the patient's condition is monitored before administering medications.
2. Accountability: Nurses are responsible for ensuring accurate documentation of vital signs. Asking the NAP to record them maintains accountability within the healthcare team.
3. Communication: By requesting the NAP to record vital signs, the nurse fosters effective communication and collaboration in patient care.
Summary of Other Choices:
A: Administering medications without reviewing vital signs could lead to adverse effects if there are abnormalities.
B: Reviewing vital signs upon return delays immediate action and could jeopardize patient safety.
D: Omitting vital signs neglects the essential monitoring required for patient care and could result in missed opportunities for early intervention.
Which part of the brain controls breathing?
- A. Medulla
- B. Cerebrum
- C. Cerebellum
- D. Thalamus
Correct Answer: A
Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.
A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults?
- A. Follicular carcinoma
- B. Anaplastic carcinoma
- C. Medullary carcinoma
- D. Papillary carcinoma
Correct Answer: D
Rationale: The correct answer is D: Papillary carcinoma. This is the most common form of thyroid cancer in adults, accounting for about 80% of cases. It is typically slow-growing and has a good prognosis. Papillary carcinoma arises from the follicular cells of the thyroid gland. Follicular carcinoma (choice A) is less common than papillary carcinoma and arises from the follicular cells as well. Anaplastic carcinoma (choice B) is a highly aggressive and rare form of thyroid cancer. Medullary carcinoma (choice C) originates from the parafollicular C cells of the thyroid gland and is not as common as papillary carcinoma. Therefore, the most appropriate choice is D, papillary carcinoma, due to its high prevalence and relatively favorable prognosis.
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. “Anemia prevents your lungs from absorbing oxygen effectively.”
- B. “You do not have enough hemoglobin to carry oxygen to your tissues.”
- C. “”You don’t have enough blood to feed your cells.”
- D. “You have lost a lot of blood, and that has damaged your lungs.”
Correct Answer: B
Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
- A. Consult physical therapy.
- B. Establish a new plan of care.
- C. Set new priorities for the patient.
- D. Assess the patient.
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.