Nokea
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: The correct answer is A: Antihistamines. Labyrinthitis is an inner ear condition often caused by inflammation or infection. Antihistamines help reduce symptoms like vertigo and dizziness by decreasing inflammation and fluid buildup in the inner ear. Anti-inflammatories (choice B) may help with inflammation but are not as effective for inner ear conditions. Antispasmotics (choice C) are not typically used for treating labyrinthitis. Antiemetics (choice D) are used to control nausea and vomiting, which can be symptoms of labyrinthitis but do not address the underlying cause.
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Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning.
Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation.
Step 3: These help prevent pressure ulcers and maintain proper body alignment.
Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care.
Step 5: Footboard and splint may not be relevant to his specific condition.
Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco.
Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity.
A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures.
B: Use of tilt board may not directly address the need for proper positioning to prevent contractures.
C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.
A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
- A. Decreased gastrointestinal motility
- B. Pain medication
- C. Abdominal distention
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.
A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
- A. Stool hematest
- B. Abdominal computed tomography (CT)
- C. Carcinoembryonic antigen (CEA) scan
- D. Sigmoidoscopy
Correct Answer: D
Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.