Nokea
The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?
- A. Cardiomyopathy
- B. Paroxysmal nocturnal dyspnea
- C. High-output failure
- D. Multisystem heart failure
Correct Answer: B
Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.
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A nurse is working in a neonatal intensive care unit (NICU). The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn?
- A. "You'll give us written instructions before we go home, correct?"
- B. "When my baby is just a little bigger, I'll feel more comfortable giving him a bath."
- C. "I want to make sure my husband is here, in case I don't hear everything that's said."
- D. "I'm so afraid I'll hurt my baby with all these tubes and wires."
Correct Answer: A
Rationale: The statement "You'll give us written instructions before we go home, correct?" reflects the mother's readiness to learn. This statement shows that the mother is actively seeking out resources and tools to help her understand and remember the instructions for giving her premature baby a bath. It indicates that she is willing to take responsibility for her baby's care and is thinking ahead to ensure she has the necessary information for when she is on her own at home. This statement demonstrates engagement and a proactive approach to learning, which are essential for successfully caring for a premature baby in a NICU setting.
After a stroke, sensory-perceptual changes increase the client's risk for what?
- A. Aspiration
- B. Injury
- C. Bleeding
- D. Infection
Correct Answer: B
Rationale: After a stroke, sensory-perceptual changes such as impaired proprioception, altered sensation, and decreased awareness of the affected side can increase the client's risk for injury. These changes can result in difficulties with balance, coordination, and spatial awareness, making the individual more prone to falls and accidents. It is important to implement safety measures and interventions to minimize the risk of injury in these clients, such as providing a structured environment, using assistive devices, and encouraging regular monitoring and assistance as needed.
A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. What is the mechanism of action of this drug?
- A. Prevents conversion of angiotensin I to angiotensin II
- B. Prevents beta-receptor stimulation in the heart
- C. Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells
- D. Blocks alpha-receptors in the vascular smooth muscle
Correct Answer: D
Rationale: Terazosin is an alpha-1 adrenergic receptor blocker. By blocking alpha-1 receptors in the vascular smooth muscle, terazosin causes dilation of both arteries and veins, leading to reduced peripheral vascular resistance and decreased blood pressure. This dilation effect is achieved by preventing the binding of norepinephrine to alpha-1 receptors, thereby inhibiting vasoconstriction. Terazosin is commonly used in the treatment of hypertension to help lower blood pressure by reducing the workload on the heart and improving blood flow to organs and tissues.
The nurse is determining the type of arthritis a patient is experiencing. Which assessment finding would be present if the patient has rheumatoid arthritis?
- A. Stiffness is relieved by activity
- B. Health history includes weight loss and fever
- C. Abnormal joint findings are limited to the hands
- D. Heberden’s nodes are located on the finger joints
Correct Answer: B
Rationale: In rheumatoid arthritis, the health history often includes systemic symptoms such as weight loss and fever. Rheumatoid arthritis is a chronic inflammatory autoimmune disease that affects multiple joints symmetrically. Unlike osteoarthritis where joint stiffness is often relieved by activity, stiffness in rheumatoid arthritis is typically worse in the morning and after inactivity. In rheumatoid arthritis, joint deformities can occur in various joints, not just limited to the hands. Heberden's nodes are characteristic of osteoarthritis, not rheumatoid arthritis.
A patient has developed a paralytic ileus following recent abdominal surgery. What is the most important nursing action when caring for this patient?
- A. Monitor bowel sounds every hour
- B. Maintain the patient on strict bed rest
- C. Ensure the nasogastric tube is functioning
- D. Ensure that the patient is given a clear liquid diet
Correct Answer: C
Rationale: Ensuring that the nasogastric tube is functioning is the most important nursing action when caring for a patient with a paralytic ileus. A paralytic ileus is a condition where there is a temporary paralysis of the intestine, leading to a lack of bowel motility. This can result in a buildup of gas and fluids in the intestines, causing abdominal distension, pain, and potential complications.