Nokea
What assessment is the nurse performing when a client is asked to stand with feet together, eyes open, and hands by the sides, and then asked to close the eyes while the nurse observes for a full minute?
- A. Romberg test
- B. Weber test
- C. Rinne test
- D. Babinski test
Correct Answer: A
Rationale: The correct answer is A, Romberg test. The Romberg test is used to assess balance and proprioception. During the test, the client is asked to stand with feet together, eyes open, and hands by the sides to observe their balance. Then, the client is asked to close their eyes while the nurse continues to observe for a full minute. This test helps in detecting any issues with proprioception and balance, which may be compromised in conditions affecting the nervous system. Choices B, C, and D are incorrect because the Weber test is used to assess hearing in each ear, the Rinne test is used to compare air and bone conduction of sound, and the Babinski test is used to assess the integrity of the corticospinal tract.
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A patient is starting on atorvastatin (Lipitor) for hyperlipidemia. What important instruction should the nurse provide?
- A. Take the medication at night to reduce the risk of muscle pain.
- B. Avoid consuming grapefruit juice while taking this medication.
- C. Take the medication in the morning with breakfast.
- D. Avoid taking the medication with alcohol to reduce the risk of liver damage.
Correct Answer: A
Rationale: The correct answer is A. Atorvastatin should be taken at night to reduce the risk of muscle pain and other side effects. Taking it at night aligns with the body's natural rhythm of cholesterol production, optimizing its effectiveness. Choice B is incorrect because grapefruit juice can increase the risk of side effects by affecting the metabolism of atorvastatin. Choice C is incorrect as taking atorvastatin in the morning does not maximize its effectiveness. Choice D is incorrect because alcohol consumption can increase the risk of liver damage when combined with atorvastatin.
A 10-year-old male is stung by a bee while playing in the yard. He begins itching and develops pain, swelling, redness, and respiratory difficulties. He is suffering from:
- A. Immunodeficiency
- B. Autoimmunity
- C. Anaphylaxis
- D. Tissue-specific hypersensitivity
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is a severe, immediate allergic reaction mediated by IgE. In this scenario, the symptoms of itching, pain, swelling, redness, and respiratory difficulties following a bee sting are indicative of anaphylaxis. Choice A, Immunodeficiency, refers to a weakened immune system's inability to protect the body from infections and diseases, which is not the case here. Choice B, Autoimmunity, involves the immune system attacking healthy cells and tissues by mistake, which is not the mechanism at play in anaphylaxis. Choice D, Tissue-specific hypersensitivity, does not accurately describe the immediate, systemic reaction seen in anaphylaxis.
A patient taking hormonal contraceptives will soon turn 35 years of age. She is moderately obese and has smoked for 15 years. Which of the following is most important?
- A. Begin an exercise regimen.
- B. Begin smoking cessation.
- C. Begin daily aspirin therapy.
- D. Begin taking a loop diuretic to aid weight loss.
Correct Answer: B
Rationale: The most important action for a patient taking hormonal contraceptives, who is nearing 35 years of age, moderately obese, and has a history of smoking for 15 years, is to begin smoking cessation. Women over 35, especially smokers, are at an increased risk of blood clots and cardiovascular issues when using hormonal contraceptives. Smoking cessation is crucial to reduce this risk. Beginning an exercise regimen may be beneficial for overall health but is not as critical as stopping smoking in this scenario. Daily aspirin therapy or taking a loop diuretic are not indicated in this situation and may not address the primary risk associated with hormonal contraceptives and smoking.
A client with amyotrophic lateral sclerosis (ALS) is admitted to the hospital. Which intervention should the nurse include in the plan of care?
- A. Administer muscle relaxants as prescribed.
- B. Assist the client with activities of daily living (ADLs).
- C. Provide nutritional support to prevent aspiration.
- D. Encourage the client to participate in physical therapy.
Correct Answer: C
Rationale: The correct intervention for a client with ALS is to provide nutritional support to prevent aspiration. ALS causes muscle weakness, including the muscles used for swallowing, increasing the risk of aspiration. Providing proper nutrition and support can help prevent this complication. Administering muscle relaxants (Choice A) may not be suitable for ALS as it can further weaken muscles. While assisting with ADLs (Choice B) and encouraging physical therapy (Choice D) are important aspects of care, the priority for a client with ALS is to prevent complications related to swallowing and nutrition.
A patient is being treated with amphotericin B. Which of the following statements indicates that the patient has understood the patient teaching?
- A. "The medication may cause diabetes."
- B. "The medication will cause liver necrosis."
- C. "The medication may cause kidney damage."
- D. "The medication will cause pancreatitis."
Correct Answer: C
Rationale: The correct answer is C: 'The medication may cause kidney damage.' Amphotericin B is known for its potential to cause nephrotoxicity, which can manifest as kidney damage. It is crucial for the patient to be aware of this possible adverse effect. Choices A, B, and D are incorrect because amphotericin B is not typically associated with causing diabetes, liver necrosis, or pancreatitis. Therefore, these statements do not reflect an accurate understanding of the medication's side effects.