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The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
- A. Drink more water to prevent further dehydration.
- B. Drink more calorie-dense fluids to increase caloric intake.
- C. Drink more milk and dairy products to decrease the risk of osteoporosis.
- D. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
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A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?
- A. Handwashing can prevent the spread of the disease to others.
- B. The importance of compliance with antibiotic therapy
- C. Signs and symptoms of complications, such as meningitis and septicemia
- D. The likely need for surgery to prevent scarring of the conjunctiva
Correct Answer: A
Rationale: Step 1: Handwashing is crucial in preventing the spread of viral conjunctivitis, which is highly contagious.
Step 2: Children often touch their eyes and then surfaces, aiding in disease transmission.
Step 3: Educating parents and the child on proper hand hygiene can help contain the infection.
Step 4: Antibiotics are not effective against viral infections, so compliance is not necessary.
Step 5: Complications like meningitis and septicemia are extremely rare with viral conjunctivitis.
Step 6: Surgery is not indicated for viral conjunctivitis, as it is a self-limiting condition.
Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
- A. Cardiomyopathy
- B. Mitral valve prolapse
- C. Rheumatic heart disease
- D. Congenital heart disease
Correct Answer: B
Rationale: The correct answer is B: Mitral valve prolapse. This condition is usually benign during pregnancy because the heart's workload increases, and the mitral valve is a one-way valve that prevents blood from flowing back into the left atrium. Mitral valve prolapse typically does not significantly affect the heart's ability to pump blood efficiently during pregnancy.
Rationale:
1. Cardiomyopathy (A) can worsen during pregnancy, leading to complications for both the mother and the fetus.
2. Rheumatic heart disease (C) can cause valve damage, increasing the risk of complications during pregnancy.
3. Congenital heart disease (D) varies in severity and can pose risks during pregnancy, depending on the specific condition.
Summary: Mitral valve prolapse is the correct answer as it is less likely to cause significant issues during pregnancy compared to the other options provided.
The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend?
- A. Avoid exercise of the arm for next 2 months.
- B. Keep cuticles clipped neatly.
- C. Avoid lifting objects heavier than 10 pounds.
- D. Use a sling until healing is complete.
Correct Answer: C
Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.
A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?
- A. Exostoses
- B. Otalgia
- C. Sensorineural hearing loss
- D. Presbycusis
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypercapnia
- D. Hypocapnia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin.
Incorrect choices:
B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case.
C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described.
D: Hypocapnia - This is low carbon dioxide levels