Nokea
When documenting subjective data, the nurse should do which of the following?
- A. Use the client’s own words placed in quotation marks.
- B. Paraphrase the information stated by the client.
- C. Validate the information with the client’s family prior to documentation.
- D. Record the information using nonspecific words.
Correct Answer: A
Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.
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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, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention.
A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status.
C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status.
D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle.
Explanation for other choices:
A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases.
C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart.
D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.
Which of the ff adverse reactions may occur when a client is taking danazol (Danocrine) for fibrocystic breast disease?
- A. Nausea
- B. Amenorrhea
- C. Confusion
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Amenorrhea. Danazol is a synthetic steroid used to treat fibrocystic breast disease by suppressing ovulation and hormonal fluctuations. This leads to a decrease in menstrual bleeding, resulting in amenorrhea. Nausea and confusion are not common adverse reactions of danazol. Hypotension is also not associated with danazol use. In summary, amenorrhea is the expected side effect due to the drug's mechanism of action, making it the correct choice compared to the other options.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.
The initial neurological symptom of Guilain-Barre Syndrome is:
- A. Absent tendon reflex
- B. Paresthesia of the legs
- C. Dysrhythmias
- D. Transient hypertension Toni a 32 year old mother of two has had multiple sclerosis for 5 years. She is currently enrolled in a school of nursing. Her husband is supportive and helps with care of their preschool sons. Toni has been admitted to the clinical area for diagnostic studies related to symptoms of visual disturbances.
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs.
Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS.
Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom.
Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation.
In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.