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To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.
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For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: C
Rationale: The correct answer is C because it focuses on the client actively engaging in reducing tension, which is essential in managing anxiety. This outcome is measurable and client-centered.
A: Verbalizing feelings is important, but it does not necessarily lead to reduction in anxiety.
B: Not guessing prognosis is helpful, but it does not address the active management of anxiety.
D: Stopping seeking information may not be beneficial as knowledge can empower the client in coping with the diagnosis.
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.
Which of the following is the most common cause of hyperaldosteronism?
- A. Excessive sodium intake
- B. Deficient potassium intake
- C. A pituitary adenoma
- D. An adrenal adenoma
Correct Answer: D
Rationale: The correct answer is D: An adrenal adenoma. Adrenal adenoma is the most common cause of primary hyperaldosteronism, also known as Conn's syndrome. Adrenal adenomas are benign tumors that cause overproduction of aldosterone, leading to increased sodium retention and potassium excretion. This results in hypertension and hypokalemia. Excessive sodium intake (A) and deficient potassium intake (B) are not direct causes of hyperaldosteronism. A pituitary adenoma (C) is associated with other hormone imbalances, such as Cushing's syndrome or acromegaly, but not hyperaldosteronism.
The patient is having difficulty coping with her new diagnosis of lymphoma. Which response by the nurse is most helpful?
- A. “Don’t worry. You’ll be okay.”
- B. “The treatments you are receiving will make you feel better very soon.”
- C. “Who do you usually go to when you have a problem?”
- D. “Have you made end-of-life decisions?”
Correct Answer: C
Rationale: The correct answer is C because it helps the patient explore her support system. By asking who she usually goes to when facing problems, the nurse encourages the patient to identify her sources of emotional support, which can help her cope with the new diagnosis. This response acknowledges the patient's need for support and fosters a therapeutic relationship.
Explanation for incorrect choices:
A: "Don't worry. You'll be okay." - This response dismisses the patient's feelings and offers false reassurance, which may not address her emotional needs.
B: "The treatments you are receiving will make you feel better very soon." - While this statement provides information about treatment, it does not directly address the patient's difficulty in coping with the diagnosis.
D: "Have you made end-of-life decisions?" - This response may be premature and could unnecessarily increase the patient's anxiety about her prognosis.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction.
Incorrect choices:
B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction.
C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing