Nokea
The nurse evaluates an improvement in the patient's heart failure (HF) status based on what assessment finding?
- A. Improved mental status.
- B. Using fewer pillows at night.
- C. Increased skin turgor.
- D. Heart rate regular.
Correct Answer: B
Rationale: The correct answer is B: Using fewer pillows at night. This indicates decreased fluid retention, a common symptom of heart failure. Improved mental status (A) may not directly correlate with HF improvement. Increased skin turgor (C) is more related to dehydration. A regular heart rate (D) is a positive sign but not specific to HF improvement.
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A patient is diagnosed as having elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what?
- A. Platelets and fibrin.
- B. Fatty streaks.
- C. White blood cells (WBC).
- D. Foam cells.
Correct Answer: B
Rationale: The correct answer is B: Fatty streaks. Fatty streaks are the earliest visible signs of atherosclerosis and are primarily composed of lipid-laden macrophages within the arterial wall. Platelets and fibrin (A) are involved in clot formation, not the initial stages of plaque formation. White blood cells (C) and foam cells (D) are involved in the later stages of atherosclerosis. The other choices are irrelevant to the initial development of plaque.
The nurse is caring for a patient that has seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as:
- A. A sign of poor self-care.
- B. A drug interaction with aspirin.
- C. An adverse effect of the phenytoin.
- D. A symptom of hepatotoxicity.
Correct Answer: C
Rationale: The correct answer is C: An adverse effect of phenytoin. Phenytoin is an antiepileptic drug known to cause gingival hyperplasia, leading to reddened and bleeding gums. This is a common side effect of phenytoin due to its effect on gingival tissues. Poor self-care (choice A) may contribute to gingival issues, but in this case, the patient's gums are affected by a medication side effect. There is no indication in the question of aspirin use (choice B) or hepatotoxicity (choice D) causing the gum issues. Therefore, the most likely explanation is the adverse effect of phenytoin.
The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident. The patient reports having bad pain. What will the nurse do first?
- A. Attempt to determine what type of pain the patient has.
- B. Request an order for intravenous opioid analgesic.
- C. Administer acetaminophen (Tylenol).
- D. Ask the patient to rate the pain on a scale of 1-10.
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to rate the pain on a scale of 1-10. This is the first step in assessing pain intensity, which helps determine the urgency and appropriate interventions needed. By having the patient rate the pain, the nurse can establish a baseline for pain management and monitor effectiveness of interventions.
Choice A is incorrect because determining the type of pain comes after assessing the intensity. Choice B is incorrect as requesting IV opioids without assessing pain intensity first may not be appropriate for a stable patient. Choice C is incorrect as administering acetaminophen should be based on the pain assessment.
A patient exhibits ptosis of both eyes and the provider orders edrophonium (Tensilon). The nurse notes immediate improvement of the ptosis. The nurse understands that this patient most likely has which disorder?
- A. Myasthenia gravis.
- B. Cerebral palsy.
- C. Multiple sclerosis.
- D. Muscle spasm.
Correct Answer: A
Rationale: The correct answer is A: Myasthenia gravis. Edrophonium is a reversible acetylcholinesterase inhibitor that improves muscle strength in patients with myasthenia gravis due to its ability to increase acetylcholine levels at the neuromuscular junction. The immediate improvement of ptosis after administration of edrophonium suggests a diagnosis of myasthenia gravis, a disorder characterized by muscle weakness and fatigability. Cerebral palsy (B) is a non-progressive neurological disorder not typically associated with ptosis and not responsive to edrophonium. Multiple sclerosis (C) is an autoimmune demyelinating disorder that does not typically present with ptosis. Muscle spasm (D) does not explain the ptosis and would not improve with edrophonium.
The nurse evaluates the effects of warfarin by monitoring what lab test?
- A. Platelet count.
- B. Activated thromboplastin time (APT).
- C. Red blood count (RBC).
- D. Prothrombin time (PT) and international normalized ratio (INR).
Correct Answer: D
Rationale: The correct answer is D: Prothrombin time (PT) and international normalized ratio (INR). Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Monitoring PT and INR levels helps assess the effectiveness and safety of warfarin therapy. PT measures the time it takes for blood to clot, while INR standardizes PT results. Platelet count (A) assesses clot formation ability, not warfarin effects. APT (B) primarily evaluates the intrinsic pathway of coagulation. RBC count (C) measures oxygen-carrying capacity, unrelated to warfarin effects.