Nokea
What are the criteria for diagnosing systemic inflammatory response syndrome (SIRS)?
- A. Dehydration
- B. Overhydration
- C. Electrolyte imbalance
- D. Hypertension
Correct Answer: A
Rationale: Dehydration results from fluid loss exceeding intake, causing symptoms like dry mucous membranes, poor skin turgor, and hypotension.
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A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
The following are the monometer measurements of four clients. Which of them has normal intraocular pressure (IOP)?
- A. 8 mm Hg
- B. 11 mm Hg
- C. 25 mm Hg
- D. 28 mm Hg
Correct Answer: B
Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore, 11 mm Hg is within the normal range.
Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.
What is a long and healthy life dependent upon?
- A. A diet high in animal fat, cholesterol, and calories
- B. Early retirement from work
- C. Vigorous physical activity once a week
- D. Interest in life
Correct Answer: D
Rationale: Interest in life contributes positively to mental health and overall well-being, which are key components of a long and healthy life.
Bob, who has Huntington's disease, tells you that he sees the same symptoms of the disease in his 13-year-old son. You respond by saying
- A. Your son probably has the early symptoms of the disease.
- B. Symptoms usually appear between the ages of 30 and 50; however, you may want to ask your physician about genetic testing that can detect if your son has the gene that is associated with Huntington's disease.
- C. Symptoms usually appear before the age of 30; you may want to ask your physician about genetic testing.
- D. Huntington's disease is genetically transmitted.
Correct Answer: B
Rationale: Huntington's disease typically manifests in adulthood, but genetic testing can confirm early cases.