Nokea
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation. Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.
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The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for Parkinson's disease as it is converted to dopamine in the brain, replenishing dopamine levels which are depleted in Parkinson's. Selegiline and Symmetrel provide symptomatic relief but are not as effective as Levodopa. Permax is not commonly used due to its association with serious side effects like heart valve damage.
A client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?
- A. Breast cancer
- B. Lung cancer
- C. Brain cancer
- D. Colon and rectal cancer
Correct Answer: B
Rationale: The correct answer is B: Lung cancer. It causes the most deaths in women because it is often diagnosed at advanced stages when treatment options are limited. Breast cancer, although common, has a higher survival rate. Brain cancer is relatively rare compared to lung cancer. Colon and rectal cancer, while prevalent, do not surpass lung cancer in terms of mortality rates in women.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.
Minda, a 65-year old female has been admitted with a left hemisphere stroke. Which behavioral change would the nurse expect to find upon assessment?
- A. impulsive, unsafe activity
- B. motor deficits on the right eye
- C. motor deficits on the left side of the body
- D. error in word choices
Correct Answer: D
Rationale: The correct answer is D: error in word choices. In left hemisphere stroke, language and speech centers are usually affected, leading to aphasia. This results in errors in word choices, difficulty expressing thoughts, and understanding language. Impulsivity and unsafe activities (choice A) are more commonly associated with frontal lobe damage. Motor deficits on the right eye (choice B) and left side of the body (choice C) are typical in strokes affecting the motor cortex, which is located in the contralateral hemisphere.
The most common buffer system in the body is the:
- A. Plasma protein buffer system
- B. Phosphate buffer system
- C. Hemoglobin buffer system
- D. Bicarbonate-carbonic system
Correct Answer: D
Rationale: The correct answer is D, the bicarbonate-carbonic system. This buffer system is crucial in maintaining the body's pH balance. When CO2 combines with water in the blood, it forms carbonic acid, which dissociates into bicarbonate ions and hydrogen ions. Bicarbonate acts as a base, accepting excess hydrogen ions to prevent a decrease in pH. Hemoglobin and plasma proteins primarily function as transport molecules, not as buffer systems. Phosphate buffer system is present in intracellular fluids, not as commonly in the body. The bicarbonate-carbonic system is the most prevalent buffer system in the blood and plays a vital role in regulating blood pH.