Nokea
When an edrophonium (Tensilon) test is carried out, which of the following drugs must be available as an antidote?
- A. Atropine sulfate
- B. Diazepam (Valium)
- C. Ephedrine
- D. Corticosteroids
Correct Answer: A
Rationale: Atropine sulfate is used as an antidote for cholinergic crisis.
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A client is admitted to the floor with Systemic Lupus Erythematosus (SLE). Which of the following teaching points does the nurse stress to the client with SLE?
- A. Apply ice as instructed
- B. Avoid sunlight and ultraviolet radiation
- C. Use assistive devices appropriately
- D. Change dressing as prescribed
Correct Answer: B
Rationale: Sunlight can exacerbate lupus symptoms.
Which of the following nursing interventions is taken as a precautionary measure if shock develops when a client with spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein.
- B. Head and back are immobilized mechanically with a cervical collar and back support.
- C. Traction with weights and pulleys is applied.
- D. A turning frame is used.
Correct Answer: A
Rationale: IV access is critical for administering fluids and medications in shock.
The nurse is caring for a client with ICP. Why will the nurse position the client in bed with HOB elevated to 30 degrees?
- A. Makes it easier for the client to breathe
- B. Prevents the Valsalva maneuver
- C. Promotes venous drainage
- D. Reduces pain
Correct Answer: C
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, reducing intracranial pressure (ICP). This position helps improve cerebral perfusion and prevents complications associated with increased ICP, such as brain herniation.
A patient diagnosed with depersonalization disorder tells the nurse, It's starting again. I feel as though I'm going to float away. The nurse should help the patient by:
- A. encouraging meditation.
- B. administering an anxiolytic medication.
- C. helping the patient visualize a pleasant scene.
- D. helping the patient focus on the here and now.
Correct Answer: D
Rationale: The correct answer is D: helping the patient focus on the here and now. This is appropriate for depersonalization disorder as it helps the patient ground themselves in reality and reduce dissociative symptoms. Encouraging meditation (A) may exacerbate dissociation by further disconnecting the patient from reality. Administering an anxiolytic medication (B) may provide temporary relief but does not address the underlying issue. Helping the patient visualize a pleasant scene (C) may be soothing but may not be effective in addressing the dissociative symptoms.
In obtaining the history for the patient with carpal tunnel syndrome, you would expect to note a history of
- A. Pain and numbness or tingling sensation in the hand (over the palmar surface of the thumb, index finger, middle finger, and lateral aspect of the ring finger) that is worse at night.
- B. Crepitus (grating feeling on palpation over joint during range of motion) due to loss of articular cartilage and bony overgrowth in joint.
- C. Excessive forward curvature of the thoracic spine (kyphosis) owing to pathologic vertebral fractures, and collapsing of the anterior portion of the vertebral bodies in the thoracic area.
- D. Acute onset of excruciating pain in joint because of accumulation of uric acid within the joint.
Correct Answer: A
Rationale: Carpal tunnel syndrome symptoms include nocturnal pain and paresthesia in the median nerve distribution.