Nokea
The most serious manifestation of lead intoxication is
- A. peripheral neuropathy
- B. mental retardation
- C. anemia
- D. cerebral edema
Correct Answer: D
Rationale: Cerebral edema is the most serious manifestation of lead intoxication, as it can be life-threatening.
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Which of the ff. would the nurse explain to the patient is indicated by a Snellen chart finding 20/80?
- A. The eye can see at 80 feet what the normal eye can see at 20 feet.
- B. The eye can see at 20 feet what the normal eye can see at 80 feet.
- C. The eye can see four times what the normal eye can see.
- D. The eye sees normally.
Correct Answer: A
Rationale: The Snellen chart is a chart used to measure visual acuity. The numbers in a Snellen fraction indicate the distance from which a person with normal eyesight can see the letters on the chart. In the case of 20/80, this means that the person can see at 80 feet what a person with normal eyesight can see at 20 feet. So, option A is correct as it accurately explains what is indicated by a Snellen chart finding of 20/80.
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
- A. Provide clear liquids only until the patient can swallow solid foods.
- B. Have the patient swallow twice after each bite
- C. Place food on the unaffected side of the patient's mouth
- D. Check if the patient's mouth for pocketing of food
Correct Answer: A
Rationale: Providing clear liquids only until the patient can swallow solid foods is not recommended as it restricts the patient's diet unnecessarily. In the case of difficulty swallowing after a stroke, it is important to modify the food consistency and provide appropriate techniques to support safe swallowing. Limiting the patient to clear liquids only could lead to inadequate nutrition and hydration. Instead, it is important to modify the diet consistency and use strategies such as altering the food presentation, having the patient swallow twice after each bite, placing food on the unaffected side of the mouth, and checking for pocketing of food to help prevent aspiration.
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: Acute respiratory distress syndrome (ARDS) is a serious condition that can lead to various complications, including renal failure. When a client is experiencing ARDS, the lungs become severely inflamed and filled with fluid, which can lead to decreased oxygen levels in the blood. This decrease in oxygen can place a significant strain on the kidneys, potentially resulting in renal failure. Therefore, it is crucial for nurses to monitor the client for signs and symptoms of renal failure, such as changes in urine output, fluid imbalance, electrolyte abnormalities, and altered mental status. Timely detection and management of renal complications in clients with ARDS are essential to prevent further deterioration of the client's condition.
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
- A. White, cottage cheese-like patches on the
- B. Red, open sores on the oral mucosa
- C. Rust-colored sputum
- D. Yellow tooth discoloration
Correct Answer: B
Rationale: Stomatitis is a common side effect of chemotherapy characterized by inflammation and irritation of the mucous membranes in the mouth. This can present as red, painful sores or ulcers on the oral mucosa. The presence of red, open sores in the mouth is indicative of stomatitis and warrants assessment and intervention to manage discomfort and prevent infection in the oral cavity. The other options are not typically associated with stomatitis in the context of chemotherapy.
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
- A. Probenecid (Benemid)
- B. Cytarabine (ara-C, cystosine arabinoside [Cytosar-U])
- C. Thioguanine (6-thioguanine, 6-TG)
- D. Leucovorin (Citrovorum factor or folinic acid [wellcovirin])
Correct Answer: D
Rationale: Leucovorin, also known as folinic acid, is given concurrently with methotrexate therapy to protect normal cells from the toxic effects of methotrexate. Methotrexate is a folate antagonist that affects both cancer cells and normal cells. Leucovorin is a reduced form of folic acid that bypasses the enzyme targeted by methotrexate, allowing normal cells to continue using folate for DNA synthesis. This rescue therapy helps prevent or reduce the side effects of methotrexate, such as mucositis, myelosuppression, and other toxic effects on normal cells. It is important to administer leucovorin at the appropriate times following methotrexate administration to maximize its protective effect while maintaining the efficacy of the chemotherapy.