Nokea
The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?
- A. Difficult to prevent
- B. Treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi, which enters the skin through the bite of an infected deer tick. It is primarily transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks carry the bacterium in their gut and can transmit it to humans when they feed on blood. Therefore, Lyme disease is characterized by being caused by a spirochete that enters the skin through a tick bite. Option C is the correct answer in this case, as options A, B, and D do not accurately describe the characteristics of Lyme disease.
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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: Macular degeneration primarily affects the macula, which is responsible for central vision. Therefore, symptoms typically include loss of central vision, decreased ability to distinguish colors, and loss of near vision. Loss of peripheral vision is not a common symptom associated with macular degeneration. Instead, it is more commonly seen in conditions affecting the peripheral retina, such as retinitis pigmentosa.
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: Furosemide IV is a diuretic medication commonly used to treat conditions such as pulmonary edema. In the case of pulmonary edema, the excess fluid accumulates in the lungs, leading to symptoms such as difficulty breathing, wheezing, and the production of pink, frothy sputum. The presence of pink, frothy sputum is a classic sign of pulmonary edema and indicates the presence of fluid in the airways. Therefore, the nurse would evaluate the effectiveness of furosemide IV treatment by monitoring the resolution of this specific symptom, as it indicates improvement in the underlying condition of pulmonary edema.
An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client's plan of care?
- A. Stop digitalis therapy
- B. Observe for trousseau's and chovestek's
- C. Avoid foods rich in potassium signs
- D. Observe for digitalis toxicity
Correct Answer: C
Rationale: The client's low potassium level (K 3.2 mEq/L) is a cause for concern, especially in a patient on digitalis therapy. Digitalis (such as digoxin) can potentiate the effects of hypokalemia, leading to an increased risk of digitalis toxicity. Therefore, in this scenario, it is important to avoid foods rich in potassium to prevent further lowering of the potassium level. It is essential to address the electrolyte imbalance promptly to prevent potential complications related to digitalis therapy.
Which characteristic is representative of the newborn's gastrointestinal tract?
- A. Stomach capacity is approximately 90 ml.
- B. Peristaltic waves are relatively slow.
- C. Overproduction of pancreatic amylase occurs.
- D. Intestines are shorter in relation to body size.
Correct Answer: D
Rationale: The characteristic representative of the newborn's gastrointestinal tract is that the intestines are shorter in relation to the body size. This is because a newborn's gastrointestinal tract is still developing and adapting to the digestion and absorption of nutrients. The proportion of the intestines to the body size is smaller in newborns compared to adults. Over time, as the newborn grows and matures, the intestines will also lengthen and increase in capacity to efficiently process food and absorb nutrients.
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.