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The nurse is aware that multiple sclerosis is a progressive disease of the central nervous system characterized by:
- A. Axon degeneration
- B. Sclerosed patches of nervous system
- C. Demyelination of the brain and spinal cord
- D. All of the above
Correct Answer: D
Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system.
Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission.
Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system.
Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS.
Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.
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In addition to antibiotics, which of the ff. recommendations can the nurse make to increase comfort in a patient experiencing sinusitis? Choose all answers that are correct. i. Coughing and deep breathing iv. Room humidifier ii. Sinus irrigation v. Percussion and postural drainage iii. Hot moist packs vi. Semi-fowler’s position
- A. 1 ,2 and 5
- B. 1, 3, 4 and 5
- C. 3, 4 and 6
- D. 2, 4, 5 and 6
Correct Answer: D
Rationale: The correct answer is D: 2, 4, 5, and 6.
1. Room humidifier (choice 2) helps to keep the air moist, which can ease sinus pressure and discomfort.
2. Hot moist packs (choice 4) can provide relief by reducing congestion and promoting sinus drainage.
3. Percussion and postural drainage (choice 5) can help loosen mucus and improve drainage.
4. Semi-fowler's position (choice 6) can also aid in drainage and reduce sinus pressure.
Choices A, B, and C are incorrect because they do not include all the recommended interventions that can help increase comfort in a patient with sinusitis. Each of the incorrect choices is missing at least one crucial recommendation that is beneficial for managing sinusitis symptoms.
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?
- A. The need to have nutrition
- B. The need to feel good about oneself
- C. The need to live in a safe environment
- D. The need for love from others
Correct Answer: B
Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.
The following are known to be causes of hepatitis except:
- A. virus
- B. toxin
- C. bacteria
- D. chemicals and drugs
Correct Answer: C
Rationale: The correct answer is C: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.
A patient with a history of haemophilia A arrives in the emergency department complaining of a “funny feeling” in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
- A. Palpate the patient’s elbow to assess for swelling.
- B. Notify the physician immediately and expect an order for factor VIII.
- C. Prepare the patient for an x-ray examination to determine whether bleeding is occurring.
- D. Apply heat to the patient’s elbow and wait for the physician to examine the patient.
Correct Answer: B
Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention.
Choices A, C, and D are incorrect:
A: Palpating the elbow could exacerbate the bleeding and cause further damage.
C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding.
D: Applying heat can increase blood flow to the joint, worsening the bleeding.
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient’s toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.