Nokea
The nurse is teaching a class on muscular coordination and explains it is the movement of what electrolyte that contributes to the process of muscle contraction and relaxation?
- A. Magnesium.
- B. Chloride.
- C. Calcium.
- D. Hydrogen.
Correct Answer: C
Rationale: The correct answer is C: Calcium. Calcium plays a crucial role in muscle contraction and relaxation. During muscle contraction, calcium ions bind to proteins in muscle fibers, allowing the actin and myosin filaments to slide past each other. This sliding action is what causes muscle contraction. When muscle relaxation is needed, calcium ions are pumped back into storage within the muscle cells, leading to relaxation. Magnesium (A), chloride (B), and hydrogen (D) do not directly influence muscle contraction and relaxation like calcium does.
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What drug would the nurse administer to treat a patient diagnosed with bronchospasm associated with chronic obstructive pulmonary disease (COPD)?
- A. Glycopyrrolate.
- B. Ipratropium.
- C. Atropine.
- D. Flavoxate.
Correct Answer: B
Rationale: The correct answer is B: Ipratropium. Ipratropium is an anticholinergic bronchodilator that helps relax the muscles in the airways, making it effective in treating bronchospasm in COPD. Glycopyrrolate (A) is also an anticholinergic but not commonly used for bronchospasm. Atropine (C) is not typically used for COPD-related bronchospasm. Flavoxate (D) is a urinary antispasmodic and not indicated for bronchospasm.
The nurse is caring for a patient with Parkinson's Disease. While writing the care plan for the patient, what would be an appropriate diagnosis?
- A. Constipation related to dopaminergic effects.
- B. Risk for injuries related to CVS effects and PVD.
- C. Risk for injury related to CVS effects and incidence of orthostatic hypotension.
- D. Diarrhea related to dopaminergic effects.
Correct Answer: C
Rationale: The correct answer is C, "Risk for injury related to CVS effects and incidence of orthostatic hypotension." This is the most appropriate diagnosis for a patient with Parkinson's Disease because they are at increased risk for falls due to cardiovascular (CVS) effects such as orthostatic hypotension, which can lead to dizziness and falls. This diagnosis addresses the specific risk factor associated with Parkinson's Disease and focuses on preventing potential injuries.
Choice A, "Constipation related to dopaminergic effects," is incorrect as constipation is a common symptom in Parkinson's Disease but does not directly relate to the risk of injury.
Choice B, "Risk for injuries related to CVS effects and PVD," is incorrect because it includes peripheral vascular disease (PVD) which is not typically associated with Parkinson's Disease.
Choice D, "Diarrhea related to dopaminergic effects," is also incorrect as diarrhea is not a common symptom or risk factor for patients with Parkinson's Disease.
The nurse is teaching a group of parents about the use of syrup of ipecac. Which instruction will the nurse provide?
- A. Give ipecac with a glass of milk to increase emetic effect.
- B. Do not administer ipecac without consulting a poison control center.
- C. Use ipecac fluid extract and not ipecac syrup.
- D. Expect the impact of emesis to be immediate.
Correct Answer: B
Rationale: The correct answer is B: Do not administer ipecac without consulting a poison control center. This is because ipecac is no longer recommended for use in cases of poisoning. It can actually be harmful and may delay the use of more effective treatments. Consulting a poison control center is essential to get guidance on the appropriate course of action.
Choice A is incorrect because giving ipecac with milk is not recommended and does not increase its emetic effect. Choice C is incorrect as ipecac syrup is the common form used, not the fluid extract. Choice D is incorrect because the impact of emesis may not be immediate and can vary depending on the individual and the substance ingested.
The nurse is caring for a patient receiving warfarin and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which?
- A. Vitamin K Level.
- B. PTT and aPTT.
- C. International normalized ratio (INR).
- D. Platelet level.
Correct Answer: C
Rationale: The correct answer is C: International normalized ratio (INR). When a patient on warfarin presents with bruising and petechiae, it suggests potential over-anticoagulation. INR measures the effectiveness of warfarin therapy by assessing clotting time. An elevated INR indicates a higher risk of bleeding due to excessive anticoagulation. Ordering a Vitamin K level (choice A) is not necessary as the patient is already on warfarin. PTT and aPTT (choice B) are not specific to monitoring warfarin therapy. Platelet level (choice D) is not indicated for assessing warfarin effects.
A patient is diagnosed as having elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what?
- A. Platelets and fibrin.
- B. Fatty streaks.
- C. White blood cells (WBC).
- D. Foam cells.
Correct Answer: B
Rationale: The correct answer is B: Fatty streaks. Fatty streaks are the earliest visible signs of atherosclerosis and are primarily composed of lipid-laden macrophages within the arterial wall. Platelets and fibrin (A) are involved in clot formation, not the initial stages of plaque formation. White blood cells (C) and foam cells (D) are involved in the later stages of atherosclerosis. The other choices are irrelevant to the initial development of plaque.