Nokea
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?
- A. TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30
- B. It can occur in clients taking antipsychotic drugs longer than 2 years
- C. Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible
- D. TD can easily be treated with anticholinergic drugs
Correct Answer: B
Rationale: Tardive dyskinesia is an extrapyramidal side effect that typically develops after prolonged use of antipsychotic drugs, often longer than 2 years, and is not easily reversible or treated with anticholinergics.
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Anaphylactic shock is a serious type of blood transfusion reaction.
The pathophysiology of anaphylaxis is
- A. It is treated with adrenalin or epinephrine.
- B. A severe vasoconstriction and profound bronchodilation.
- C. Characterized by presence of rashes all throughout the body.
- D. A profound hypotension due to profound vasodilation and severe bronchoconstriction.
Correct Answer: D
Rationale: Anaphylaxis involves vasodilation and bronchoconstriction, leading to hypotension and respiratory distress.
The nurse is caring for a client with a tracheostomy. Which of the following actions should the nurse perform to prevent complications?
- A. Suction the tracheostomy every 8 hours.
- B. Clean the inner cannula with sterile technique.
- C. Change the tracheostomy ties daily.
- D. Use a dry gauze dressing around the tracheostomy site.
Correct Answer: B
Rationale: Cleaning the inner cannula with sterile technique prevents infection and ensures airway patency, a priority in tracheostomy care. Suctioning (A) is as needed, not routine, tie changes (C) are less frequent, and dressings (D) should be pre-cut and moisture-resistant.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
Hirschprung's Disease is somewhat similar to cystic fibrosis. In both diseases, the newborn does not pass out meconium.
Pathophysiologically, in Hirschprung's Disease, the child's affected organ is:
- A. Small intestine
- B. Large intestine
- C. Stomach
- D. Liver
Correct Answer: B
Rationale: Hirschprung's disease involves aganglionic segments of the large intestine, causing obstruction.
A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.