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The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
- A. Fasciculations
- B. Chorea
- C. Atrophy
- D. Neuropathy
Correct Answer: A
Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.
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An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues.
A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care.
B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications.
C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D.
Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
- A. Weigh the client.
- B. Administer oral hydrocortisone.
- C. Test urine for ketones.
- D. Assess vital signs.
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Mr. Ramos consulted at the health center for follow up after one month of Isoniazid and Rifampicin. Which diagnostic test will have an abnormal result if the client is taking these medications?
- A. gallbladder studies
- B. thyroid function tests
- C. liver function tests
- D. blood sugar levels
Correct Answer: C
Rationale: The correct answer is C: liver function tests. Isoniazid and Rifampicin are known to potentially cause hepatotoxicity, leading to abnormal liver function test results. Liver function tests measure enzymes and proteins that indicate liver health. Gallbladder studies (A), thyroid function tests (B), and blood sugar levels (D) are not directly affected by these medications and would not show abnormal results due to their use.