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What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.
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An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client “looks like he is having difficulty getting air.” What should the nurse’s initial action be?
- A. Thank the client’s sister and continue to observe the client
- B. Immediately decrease the oxygen
- C. Notify the physician
- D. elevate client’s head and take her vital signs
Correct Answer: C
Rationale: The correct initial action for the nurse is to choose option C: Notify the physician. Increasing oxygen without a healthcare provider's order can be harmful, especially in COPD patients prone to retaining carbon dioxide. The nurse should communicate the situation to the physician to assess the client's condition and adjust the oxygen therapy appropriately. Option A is incorrect as it neglects the potential risks of high oxygen levels. Option B is incorrect as immediate decrease without proper assessment can be dangerous. Option D is not the priority when the client's oxygen therapy needs evaluation.
The nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?
- A. Painful mouth sores
- B. Nausea and vomiting
- C. Frequent diarrhea
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications.
A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect.
C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting.
D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.
A patient teaching plan should include which of the ff. lifestyle modifications to help control hypertension?
- A. Regular aerobic exercise
- B. Three alcoholic beverages per day
- C. Low-tar cigarettes
- D. Daily multivitamin supplements
Correct Answer: A
Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation.
Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control.
Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided.
Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects.
Step 5: Daily multivitamin supplements do not directly impact blood pressure control.
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT.
Rationale:
A) RBC count: AZT can cause anemia, not specifically affecting the RBC count.
B) Serum calcium: AZT does not typically affect calcium levels.
C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.
A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient?
- A. Identify factors interfering with goal achievement.
- B. Counsel the nursing assistive personnel on duty when the patient fell. Remove the fall risk sign from the patient’s door because the patient has suffered a
- C. fall. Request that the more experienced charge nurse complete the documentation about
- D. the fall.
Correct Answer: A
Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls.
Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall.
Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall.
Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.