Nokea
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
- A. Maintain strict isolation
- B. Wear gloves when providing mouth care
- C. Keep the client in a private room, if
- D. Wear a gown when delivering the client's possible food tray
Correct Answer: B
Rationale: Standard precautions are guidelines put in place to prevent the transmission of infectious agents. When caring for a client with AIDS, it is important for the nurse to wear gloves when providing mouth care to prevent the transmission of any potential infectious agents through contact with the client's saliva or blood. Maintaining strict isolation, keeping the client in a private room, or wearing a gown when delivering the client's possible food tray are not necessary as part of standard precautions for a client with AIDS.
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The first permanent tooth to erupt is
- A. central incisor at 6 yr
- B. molar at 6 yr
- C. premolar lower canine at 6-7 yr
- D. upper canine at 6-7 yr
Correct Answer: B
Rationale: The first permanent molar typically erupts around 6 years.
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
- A. exophthalmos and conjunctival redness
- B. flushed, warm, moist skin
- C. systolic murmur at the left sternal border
- D. decreased body temperature and cold intolerance
Correct Answer: D
Rationale: The correct assessment findings to stay alert for when evaluating for hypothyroidism are decreased body temperature and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a decrease in metabolic rate. This can result in symptoms such as feeling cold all the time and a lower body temperature. Therefore, the nurse should keep an eye out for these symptoms during the assessment of a client being evaluated for hypothyroidism. Symptoms such as exophthalmos and conjunctival redness are more commonly associated with hyperthyroidism.
After surgery the nurse notes that the patient's urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
- A. The sympathetic nervous system saves fluid in response to stress of surgery.
- B. The sympathetic nervous system diereses fluid in response to stress of surgery.
- C. The parasympathetic nervous system saves fluid in response to stress of surgery.
- D. The parasympathetic nervous system diereses fluid in response to stress of surgery.
Correct Answer: A
Rationale: The sympathetic nervous system saves fluid in response to the stress of surgery, leading to the urine becoming dark amber and concentrated. During stressful events such as surgery, the body activates the sympathetic nervous system as part of the fight-or-flight response. One of the functions of the sympathetic nervous system in this situation is to conserve fluids in the body by reducing urine output. This results in more concentrated urine, often appearing dark amber in color. Conversely, the parasympathetic nervous system is not typically involved in conserving fluid during stress responses.
If a patient has severe hyperkalemia, it is possible to administer calcium gluconate intravenously to:
- A. Immediately lower the potassium level by
- B. Prevent transient renal failure (TRF)
- C. Accomplish all of the above
- D. Antagonize the action of K on the heart
Correct Answer: D
Rationale: Calcium gluconate is administered intravenously in the setting of severe hyperkalemia to antagonize the effects of potassium on the heart. Hyperkalemia can lead to dangerous cardiac arrhythmias due to the changes in membrane potential of cardiac cells caused by increased extracellular potassium levels. Administration of calcium gluconate helps stabilize the cardiac cell membrane potential, protecting against the risk of life-threatening arrhythmias. It doesn't provide an immediate decrease in serum potassium levels (Choice A) or prevent transient renal failure (TRF) (Choice B). Therefore, the correct answer is D, as calcium gluconate primarily acts to counteract the effects of hyperkalemia on the heart.
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.