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What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
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A surgical intervention that can cause substantial remission of myasthenia gravis is:
- A. Esophagostomy
- B. Thymectomy
- C. Myomectomy
- D. Spleenectomy
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. The thymus gland is often found to be abnormal in individuals with myasthenia gravis, and removing it through thymectomy can lead to substantial remission of symptoms. This is because the thymus plays a role in the development of the immune system and may be producing antibodies that attack neuromuscular junctions in myasthenia gravis.
Choice A, esophagostomy, is a surgical procedure to create an opening in the esophagus for feeding and has no direct impact on myasthenia gravis. Choice C, myomectomy, is the removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, spleenectomy, is the removal of the spleen and is not a treatment for myasthenia gravis as the spleen is not implicated in the disease process.
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
- A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
- B. Slow the transfusion and monitor the client closely.
- C. Stop the transfusion, notify the blood bank, and administer antihistamines
- D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank
Correct Answer: D
Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank.
Rationale:
1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction.
2. Infuse normal saline solution to maintain adequate hydration and support kidney function.
3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing.
Summary of other choices:
A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical.
B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively.
C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.
Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.
Which screening test for colorectal cancer should the nurse recommend?
- A. Carcinoembryonic antigen (CEA) test
- B. Annual digital examination after age 50
- C. Barium enema after age 50
- D. Proctosigmoidoscopy after age 50
Correct Answer: D
Rationale: The correct screening test for colorectal cancer is D: Proctosigmoidoscopy after age 50. This test allows direct visualization of the lower colon and rectum, aiding in the detection of polyps or tumors. It is recommended for individuals over 50 years old to screen for colorectal cancer. A: CEA test is not a primary screening tool but rather used for monitoring cancer progression. B: Annual digital examination is not sufficient for colorectal cancer screening. C: Barium enema is less effective compared to colonoscopy for detecting abnormalities in the colon.
Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: The correct answer is C: Halos around lights. This symptom is specific to acute angle-closure glaucoma due to increased intraocular pressure causing corneal edema. Halos around lights are caused by light diffraction through edematous cornea. Flashing lights and lens opacity are not typically associated with acute angle-closure glaucoma. Flashing lights may be seen in retinal detachment, while lens opacity is more commonly seen in cataracts.