Nokea
The wife of a patient who has a ruptured aneurysm asks how this could have happened considering that he passed a physical 3 months ago. What is the best response?
- A. Aneurysms are often asymptomatic.
- B. The physician must have misread the x-ray.
- C. The aneurysm must have developed since his physical.
- D. Do not be too concerned because this happens all the time.
Correct Answer: A
Rationale: Aneurysms can develop over time and may not show symptoms until they rupture.
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The nurse is providing post-procedure care for a patient recovering from a lumbar puncture. Which order should the nurse anticipate for this patient?
- A. Keep the patient NPO for 4 hours.
- B. Have the patient lie flat for 6 hours.
- C. Monitor the patient's pedal pulses every 4 hours.
- D. Keep the head of the bed elevated 30 degrees for 8 hours.
Correct Answer: B
Rationale: After a lumbar puncture, the patient should lie flat for 6 to 8 hours to prevent cerebrospinal fluid leakage and reduce the risk of a spinal headache. Monitoring pedal pulses or elevating the head of the bed is not necessary. Proper post-procedure care minimizes complications.
During the acute phase of dermatomyositis, what is an appropriate patient outcome?
- A. Relates improvement in pain
- B. Does not experience aspiration
- C. Performs active ROM four times daily
- D. Maintains absolute rest of affected joints
Correct Answer: B
Rationale: Preventing aspiration is critical in dermatomyositis.
Which action requires immediate intervention by the nurse for a nursing assistant caring for a patient with CTS?
- A. Arrange the patient's lunch tray and cut the meat.
- B. Provide warm water and assist the patient with a bath.
- C. Replace the patient's splint in hyperextension position.
- D. Remind the patient not to lift very heavy objects.
Correct Answer: C
Rationale: Replacing a splint in hyperextension without proper training could exacerbate the condition.
Which structure and its secretion are correctly matched?
- A. prostate - fibrinolysin
- B. bulbourethral gland - thick, acidic fluid
- C. epididymis - testosterone
- D. seminal vesicles - fructose
Correct Answer: D
Rationale: The seminal vesicles are correctly matched with fructose because they secrete a fluid rich in fructose, which provides energy for sperm motility. This fluid makes up a significant portion of semen and is essential for sperm survival and function. The other options are incorrect because they do not accurately describe the secretions of the respective structures.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. You will need to accept the necessity for a quiet and inactive lifestyle.
- B. Keep active, use stress reduction strategies, and avoid fatigue.
- C. Follow good health habits to change the course of the disease.
- D. Practice using the mechanical aids that you will need when future disabilities arise.
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management is essential for maintaining quality of life in MS. A completely inactive lifestyle is not recommended.