What is the most sensitive indicator of altered brain function?
- A. The ability to perform complex mathematics
- B. Altered level of consciousness
- C. The lack of cerebrospinal fluid production
- D. Intact cranial nerve functions
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. Changes in consciousness are the most sensitive indicator of altered brain function as they can signal underlying neurological issues. Option A, the ability to perform complex mathematics, though it involves brain function, is not as sensitive or direct an indicator as altered consciousness. Option C, the lack of cerebrospinal fluid production, is more related to conditions like hydrocephalus rather than a direct indicator of altered brain function. Option D, intact cranial nerve functions, indicate the normal functioning of peripheral nerves and are not as sensitive to changes in brain function as alterations in consciousness.
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Which of the following would the nurse expect to see in a client experiencing hypoventilation?
- A. Increased oxygenation in the alveoli
- B. Increased carbon dioxide in the bloodstream
- C. Decreased hemoglobin in the bloodstream
- D. Decreased carbon dioxide in the alveoli
Correct Answer: B
Rationale: In hypoventilation, there is inadequate ventilation leading to decreased removal of carbon dioxide. This results in increased carbon dioxide in the bloodstream. The other choices are incorrect because hypoventilation does not improve oxygenation in the alveoli (Choice A), decrease hemoglobin in the bloodstream (Choice C), or decrease carbon dioxide in the alveoli (Choice D).
Which of the following describes the damage to the brain that results in cerebral palsy?
- A. Reversible with cognitive therapy in infancy
- B. Transient and resolves in adulthood through physical therapy
- C. Manifests in adulthood after regular childhood activities
- D. Irreversible and occurs before, during, or after birth or infancy
Correct Answer: D
Rationale: The correct answer is D. Cerebral palsy involves irreversible damage to the brain that occurs before, during, or shortly after birth, impacting movement and coordination. Choices A, B, and C are incorrect because cerebral palsy is not reversible with cognitive therapy or physical therapy, does not resolve in adulthood, and does not manifest in adulthood after regular childhood activities.
When teaching a young woman about the use of hormonal contraceptives, a nurse should emphasize that these drugs are most effective when taken:
- A. Immediately after sexual intercourse.
- B. At the same time each day.
- C. Before going to bed at night.
- D. On an empty stomach.
Correct Answer: B
Rationale: The correct answer is B: 'At the same time each day.' Hormonal contraceptives should be taken consistently at the same time each day to maintain stable hormone levels, which is crucial for their effectiveness. Taking them at random times can increase the risk of contraceptive failure. Choices A, C, and D are incorrect because taking hormonal contraceptives immediately after sexual intercourse, before going to bed at night, or on an empty stomach does not align with the recommended usage instructions for these drugs.
A patient is starting on atorvastatin (Lipitor) for hyperlipidemia. What critical instruction should the nurse provide?
- A. Take the medication at night to reduce the risk of muscle pain and other side effects.
- B. Avoid consuming grapefruit juice while taking this medication.
- C. Take the medication in the morning with breakfast to improve absorption.
- D. Take the medication with a high-fat meal to increase its effectiveness.
Correct Answer: A
Rationale: The correct answer is to take the medication at night to reduce the risk of muscle pain and other side effects. Atorvastatin, like other statins, is more effective when taken in the evening as the body produces more cholesterol at night. Taking it with a high-fat meal (choice D) is not recommended as it may reduce the drug's absorption. Grapefruit juice (choice B) should be avoided with atorvastatin as it can increase the risk of side effects. Taking the medication in the morning with breakfast (choice C) is not as effective as taking it at night.
What clinical manifestations would the nurse expect to find in a client who is experiencing anaphylaxis?
- A. Dilated bronchioles, constriction of peripheral blood vessels, decreased capillary permeability
- B. Asthma, deep vein thrombosis, hepatic encephalopathy
- C. Narrowing of the bronchioles, dilation of the peripheral blood vessels, increased capillary permeability
- D. Left-sided heart failure, pulmonary embolism, urinary tract infection
Correct Answer: C
Rationale: In anaphylaxis, the client would present with narrowing of the bronchioles, dilation of the peripheral blood vessels, and increased capillary permeability. These manifestations lead to symptoms such as difficulty breathing, low blood pressure, and swelling. Choices A, B, and D are incorrect because they do not describe the typical clinical manifestations of anaphylaxis.