Which system is primarily affected by tuberculosis (Mycobacterium)?
- A. stomach (GI)
- B. heart (cardiac)
- C. lungs (respiratory)
- D. skin (integumentary)
Correct Answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
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A 93-year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
- A. Recommend the patient remain in her room at all times.
- B. Recommend family members bring pictures to the patient's room.
- C. Recommend a speech therapy consult to the doctor.
- D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct Answer: B
Rationale: For a 93-year-old female with Alzheimer's Disease exhibiting signs of increased confusion and limited stability with gait, recommending family members to bring pictures to the patient's room is the most appropriate course of action. Visual stimulation in the form of pictures may help decrease signs of confusion and provide comfort to the patient. Option A is incorrect as isolating the patient in her room at all times may worsen her condition by further limiting stimulation and interaction. Option C is incorrect as speech therapy may not directly address the current issues of confusion and gait instability. Option D is incorrect as pushing a wheelchair may not be safe for the patient if she is refusing to use it, potentially leading to falls or further distress.
A patient who has delivered an 8.2 lb. baby boy 3 days ago via c-section, reports white patches on her breast that aren't going away. Which of the following medications may be necessary?
- A. Nystatin
- B. Atropine
- C. Amoxil
- D. Lortab
Correct Answer: A
Rationale: The patient is likely experiencing thrush, a fungal infection, which can present as white patches on the breast that persist. Nystatin is an antifungal medication commonly used to treat thrush. Therefore, the correct answer is Nystatin. Atropine is not indicated for this condition and is used for different purposes. Amoxil is an antibiotic and would not be effective against a fungal infection like thrush. Lortab is a pain medication and is not appropriate for treating thrush.
Which statement best describes electrolytes in intracellular and extracellular fluid?
- A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
- B. There is an equal concentration of sodium and potassium in extracellular fluid
- C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
- D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid
Correct Answer: A
Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.
A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?
- A. Create an atmosphere of seclusion for the boy according to procedures.
- B. Remove other patients from the area for added safety.
- C. Ask the patient, "What is making you mad?"?
- D. Ask the patient, "Why are you behaving this way? Have you thought about what may help you calm down?"?
Correct Answer: A
Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation. Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.
A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:
- A. "I will talk to the doctor about it."?
- B. "Has this been going on for a while?"?
- C. "How do you know this?"?
- D. "Teenagers often exhibit signs of sexual interest in females."?
Correct Answer: D
Rationale: The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.