Nokea
Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?
- A. Patch one eye and then the other every few hours
- B. Encourage bedrest until the diplopia is resolved
- C. Instruct the client to limit intake of oral fluids
- D. Administer artificial tear drops to both eyes
Correct Answer: A
Rationale: Patching each eye helps alleviate double vision caused by MS-related vision impairment.
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A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
Diseases that primarily involve the motor unit include:
- A. Werdnig-Hoffman disease
- B. Guillain-Barre syndrome
- C. Facioscapulohumeral dystrophy
- D. Charcot-Marie-Tooth disease
Correct Answer: A
Rationale: Werdnig-Hoffman disease, also known as spinal muscular atrophy type 1, primarily affects the motor neurons in the spinal cord.
The following enzymes and inhibitors are matched correctly:
- A. Xanthine oxidase-allopurinol
- B. Enolase-fluoride
- C. Cholinesterase-physostigmine
- D. Ceruloplasmin-penicillamine
Correct Answer: A
Rationale: Xanthine oxidase-allopurinol: Allopurinol inhibits xanthine oxidase, which plays a role in purine metabolism, and is used to treat gout and prevent uric acid buildup.
The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse's best response is:
- A. It is always helpful to get a second opinion about any serious condition like this.
- B. Your baby's defect is small and will likely close on its own by 1 year of age.
- C. It is common for physicians to wait until an infant develops respiratory distress before they do the surgery.
- D. With a small defect like this, they wait until the child is 10 years old to do the surgery.
Correct Answer: B
Rationale: Most small VSDs close spontaneously within the first year of life.
Sudden death in an athlete immediately after forceful blunt trauma to the chest is most likely
- A. commotio cordis
- B. myocardial infarction
- C. lacerated coronary artery
- D. ruptured cardiac tendineae
Correct Answer: A
Rationale: Commotio cordis occurs due to sudden arrhythmias triggered by chest trauma during a vulnerable phase of the cardiac cycle.