Nokea
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.
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A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician prescribes mitomycin (Mutamycin) with other chemotherapeutic agents for palliative treatment. How mitomycin does exert its cytotoxic effects?
- A. It inhibits deoxyribonucleic acid (DNA) synthesis
- B. It inhibits ribonucleic acid (RNA) synthesis
- C. It’s cell cycle-phase specific
- D. It inhibits protein synthesis
Correct Answer: A
Rationale: The correct answer is A: It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin is an alkylating agent that works by cross-linking DNA, preventing DNA synthesis and leading to cell death. This mechanism of action makes it effective against rapidly dividing cells like cancer cells.
Choice B, inhibiting ribonucleic acid (RNA) synthesis, is incorrect as mitomycin primarily targets DNA synthesis. Choice C, being cell cycle-phase specific, is incorrect as mitomycin affects cells in all phases of the cell cycle. Choice D, inhibiting protein synthesis, is incorrect because mitomycin's primary mode of action is on DNA replication, not protein synthesis.
If a patient has severe hyperkalemia, it is possible to administer calcium gluconate intravenously to:
- A. Immediately lower the potassium level by
- B. Prevent transient renal failure (TRF)
- C. Accomplish all of the above
- D. Antagonize the action of K on the heart
Correct Answer: D
Rationale: Correct Answer: D. Antagonize the action of K on the heart
Rationale:
1. Calcium gluconate stabilizes cardiac cell membranes during hyperkalemia.
2. By antagonizing the effects of potassium on the heart, it helps prevent life-threatening cardiac arrhythmias.
3. It does not lower potassium levels immediately or prevent transient renal failure.
4. Administering calcium gluconate is specific to addressing the cardiac effects of hyperkalemia, not renal or overall potassium reduction.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600mg PO every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
- A. Dysuria
- B. Tinnitus
- C. Leg cramps
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Aspirin can cause tinnitus (ringing in the ears) as an adverse drug reaction, which can indicate potential ototoxicity. Tinnitus is an important side effect that should be reported promptly to the physician to prevent further auditory complications. Dysuria (A), leg cramps (C), and constipation (D) are not typically associated with aspirin use and are less urgent compared to tinnitus. Reporting these side effects may still be necessary but are not as critical as tinnitus in this scenario.
The most significant form of meningitis is:
- A. Bacterial
- B. Septic
- C. Aseptic
- D. Viral
Correct Answer: A
Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The correct answer is A: Urinary output of 30 ml in an hour. Adequate tissue perfusion is best indicated by a sufficient urinary output, as it demonstrates proper kidney perfusion and function. A low urinary output may suggest inadequate perfusion.
Explanation for other choices:
B: Central venous pressure reading of 2 cm H20 is not a reliable indicator of tissue perfusion to vital organs.
C: Pulse rates alone are not enough to indicate tissue perfusion as they can be influenced by various factors.
D: Blood pressure readings alone may not accurately reflect tissue perfusion, especially in the context of fluid replacement therapy.