Nokea
The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is
- A. Intravenous fluid infusion
- B. Level of consciousness
- C. Pulse and respirations
- D. Extremities for injuries
Correct Answer: B
Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.
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A client with a history of hypertension is receiving enalapril (Vasotec). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia as a side effect. ACE inhibitors can cause potassium retention by inhibiting aldosterone secretion, which may result in elevated potassium levels. Hypoglycemia (choice B) is not typically associated with enalapril use. Hypercalcemia (choice C) is also not a common side effect of enalapril. Hypokalemia (choice D) is the opposite of what is expected with enalapril, as it tends to cause potassium retention.
A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:
- A. Increase acid secretion
- B. Reduce acid secretion
- C. Promote gastric emptying
- D. Remove the ulcerated area
Correct Answer: B
Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
- A. Non-intention tremors and urgency with voiding
- B. Echolalia and a shuffling gait
- C. Muscle spasm and a bent-over posture
- D. Intention tremor and jerky movement of the elbows
Correct Answer: B
Rationale: The correct answer is B. Echolalia (repeating others' words) and a shuffling gait are common symptoms of Parkinson's disease. These symptoms result from the degeneration of the basal ganglia in the brain that controls movement and speech. Choice A is incorrect because non-intention tremors are not typically associated with Parkinson's disease. Choice C is incorrect as muscle spasm and a bent-over posture are not classic manifestations of Parkinson's disease. Choice D is incorrect since intention tremors and jerky movement of the elbows are not characteristic of Parkinson's disease.
A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding transmission of anthrax should the nurse provide to the group?
- A. Infection is acquired when anthrax spores enter a host.
- B. Mature anthrax bacteria live dormant on inanimate objects.
- C. Spores cannot survive for extended periods outside a living host.
- D. Anthrax is transmitted by respiratory droplets from person to person.
Correct Answer: A
Rationale: The correct information the nurse should provide is that anthrax infection occurs when spores enter a host. Choice B is incorrect as mature anthrax bacteria do not live dormant on inanimate objects. Choice C is incorrect as anthrax spores can survive for extended periods outside a living host. Choice D is incorrect as anthrax is not transmitted by respiratory droplets from person to person.
Which of the following tools is used by community health nurses to identify the health needs of a population?
- A. Health survey
- B. Medical records
- C. Patient interviews
- D. Epidemiological studies
Correct Answer: D
Rationale: Epidemiological studies are used by community health nurses to identify the health needs of a population. These studies involve investigating patterns, causes, and effects of health and disease conditions in defined populations. While health surveys, medical records, and patient interviews are valuable tools in healthcare, epidemiological studies provide a broader population-based perspective essential for understanding and addressing community health needs.