Nokea
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above Charles is a 76 year old retired professional golfer. He has recently been diagnosed as having Parkinson’s disease.
Correct Answer: D
Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.
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Which white blood cells are involved in releasing histamine during an allergic reaction?
- A. Basophils
- B. Monocytes
- C. Eosinophils
- D. Neutrophils
Correct Answer: A
Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.
A client has the following blood lab values: platelets 50,000/ul, RBC’s 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
- A. Bleeding precautions
- B. Isolation to prevent infection
- C. Seizure precautions
- D. Control of pain with analgesics
Correct Answer: A
Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding.
Summary:
B: Isolation to prevent infection - This is not related to the client's lab values.
C: Seizure precautions - Not relevant to the client's lab values.
D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
Which of the ff blood vessel is commonly affected by thrombophlebitis?
- A. Veins deep in the upper extremities
- B. Popliteal vein of the leg
- C. Veins deep in the lower extremities
- D. Veins connected to the heart
Correct Answer: C
Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (A) are less commonly affected. The popliteal vein of the leg (B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (D) are arteries, not veins, and are not typically involved in thrombophlebitis.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Rationale:
1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport.
2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast.
3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes.
4. Patient-centered care: Addressing sleep concerns aligns with patient needs.
Incorrect answers:
A: Focusing solely on the leg and cast disregards the patient's holistic well-being.
B: Documenting without addressing the patient's concern neglects the opportunity for intervention.
C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.