Nokea
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.
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The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate" is a nursing diagnosis, not a collaborative problem. Collaborative problems involve issues that require both nursing and medical interventions, whereas nursing diagnoses focus on the nurse's role in addressing the patient's health issues. Therefore, the nurse should revise the collaborative problem part to accurately reflect the collaborative aspect of the patient's care. Etiology (A), nursing diagnosis (B), and defining characteristic (D) are not the parts of the diagnostic statement that need revision in this scenario.
Which of the following parts of neuron transmits impulses away from the cell body?
- A. Dendrite
- B. . Neurolemma
- C. Axon
- D. Synapse
Correct Answer: C
Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals.
Rationale:
1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect.
2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect.
3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.
The majority of lumbar disc herniations occur at the level of:
- A. L1 –L2
- B. L4-L5
- C. L3-L4
- D. S1-S2
Correct Answer: B
Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica. Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.
The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
- A. Nystagmus
- B. No symptoms, because this is normal
- C. Tachycardia therapeutic level
- D. Slurred speech
Correct Answer: A
Rationale: The correct answer is A: Nystagmus. A phenytoin blood level of 35 mcg/ml is above the therapeutic range (usually 10-20 mcg/ml). Excessive levels can lead to symptoms such as nystagmus, which is an involuntary eye movement commonly seen with phenytoin toxicity. Nystagmus is a known side effect of phenytoin overdose. Choices B and C are incorrect because a level of 35 mcg/ml is not within the normal therapeutic range, so symptoms would be expected. Choice D, Slurred speech, is not typically associated with phenytoin toxicity.