Nokea
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.
A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
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A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
- A. “Do you smoke cigarettes, cigars or pipe?”
- B. “Have you strained your voice recently?”
- C. “Do you eat a lot of red meat?”
- D. “Do you eat spicy foods?”
Correct Answer: B
Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention.
Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless.
Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand.
Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.
A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
- A. “I’m worried about what those other girls will think of me.”
- B. “I can’t wear that color. It makes my hips stick out.”
- C. “I’ll wear the blue dress. It matches my eyes.”
- D. “I will go to the pool next summer.”
Correct Answer: C
Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image.
A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation.
B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance.
D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.
Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?
- A. BUN and creatinine
- B. Hgb and Hct
- C. ABG
- D. Serum potassium
Correct Answer: C
Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions.
A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome.
B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome.
D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.
The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
- A. Acetylcholine
- B. Serotonin
- C. Dopamine
- D. Phenylalanine
Correct Answer: C
Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.