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The nurse is helping develop a plan of care for a patient that has advanced Alzheimer's disease. The patient will be taking a new medication. Which is a realistic goal for this patient?
- A. Exhibit ability to provide self-care.
- B. Show improved memory for recent events.
- C. Receive appropriate assistance for care needs.
- D. Demonstrate improved cognitive function.
Correct Answer: C
Rationale: The correct answer is C: Receive appropriate assistance for care needs. For a patient with advanced Alzheimer's disease, improving memory or cognitive function is unrealistic due to the progressive nature of the disease. Providing self-care may also be beyond their ability. Setting a goal for the patient to receive appropriate assistance for care needs is realistic and important for maintaining their quality of life and safety. This goal focuses on ensuring the patient's basic needs are met and promoting their overall well-being despite their cognitive decline. It prioritizes practical support and enhances the patient's quality of life.
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A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.
After completing a course on pharmacology for nurses, what will the nurse know?
- A. Everything necessary for safe drug administration.
- B. General drug information; the nurse can consult a drug guide for specific drug information.
- C. The drug actions that are associated with each classification of medication.
- D. Current pharmacologic therapy; the nurse will not require ongoing education for 5 years.
Correct Answer: B
Rationale: The correct answer is B because pharmacology courses provide general drug information, teaching nurses to consult drug guides for specific details. This knowledge includes drug classifications, actions, side effects, and interactions. Nurses must continuously update their knowledge due to new drug developments, hence ongoing education is necessary. Choice A is incorrect as pharmacology education is comprehensive but doesn't cover all aspects of safe drug administration. Choice C is incorrect because it oversimplifies pharmacology knowledge to just drug actions. Choice D is incorrect as pharmacologic therapy constantly evolves, requiring ongoing education.
What assessment finding would indicate the patient's left-sided heart failure is worsening?
- A. Increased jugular venous pressure.
- B. Liver enlargement.
- C. Increased pulse rate.
- D. Increased crackles in lung fields.
Correct Answer: D
Rationale: The correct answer is D: Increased crackles in lung fields. Worsening left-sided heart failure causes fluid to accumulate in the lungs, leading to crackles on auscultation. Increased jugular venous pressure (A) is more indicative of right-sided heart failure. Liver enlargement (B) is a sign of congestive hepatomegaly, common in right-sided heart failure. Increased pulse rate (C) may indicate heart failure exacerbation but is not specific to left-sided failure. Therefore, choice D is the best indicator of worsening left-sided heart failure.
The patient asks the nurse what atorvastatin (Lipitor) newly prescribed will do. What's the expected outcome the nurse will describe?
- A. Decrease in sitosterol and serum cholesterol.
- B. Decrease in campesterol and LDL levels.
- C. Decrease in serum cholesterol and low-density lipoprotein (LDL) levels.
- D. Decrease in serum cholesterol only.
Correct Answer: C
Rationale: The correct answer is C because atorvastatin works by inhibiting the enzyme HMG-CoA reductase, leading to a decrease in serum cholesterol and LDL levels. This is the expected outcome that the nurse will describe to the patient. Choice A is incorrect because sitosterol is not primarily targeted by atorvastatin. Choice B is incorrect as campesterol is not a main focus of atorvastatin. Choice D is incorrect because atorvastatin also targets LDL levels, not just serum cholesterol.
What is the action of ergotamine?
- A. Increases hypoperfusion of basilar artery vascular bed.
- B. Decreases hypoperfusion of basilar artery vascular bed.
- C. Increases hyperperfusion of basilar artery vascular bed.
- D. Decreases hyperperfusion of basilar artery vascular bed.
Correct Answer: D
Rationale: The correct answer is D: Decreases hyperperfusion of basilar artery vascular bed. Ergotamine is a vasoconstrictor that acts on serotonin receptors, reducing blood flow and decreasing hyperperfusion in the basilar artery. This helps in treating conditions like migraines by reducing the dilation of blood vessels. Choice A is incorrect because ergotamine does not increase hypoperfusion, but rather decreases hyperperfusion. Choice B is incorrect as ergotamine does not decrease hypoperfusion. Choice C is incorrect since ergotamine does not increase hyperperfusion, rather it decreases it.