Nokea
Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?
- A. Avoid noises
- B. Encourage fluid intake
- C. Avoid sudden movements
- D. Administer analgesics
Correct Answer: C
Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms.
Avoiding noises (A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (D) may help with pain but will not address the underlying cause of vertigo.
Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.
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Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?
- A. Measure intake and output
- B. Perform the mini-mental status
- C. Use the Glasgow Coma scale examination
- D. Assess vital signs
Correct Answer: A
Rationale: The correct answer is A: Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Electrolyte imbalances can lead to neurological complications, so accurate monitoring is essential. Mini-mental status and Glasgow Coma scale are assessments of mental status, not electrolyte balance. Vital signs can provide some information, but intake and output measurement is more specific for assessing electrolyte imbalances and dehydration.
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. “Never suction your tracheostomy; you might damage your trachea.”
- B. “”You should not feel bad about the tracheostomy – you should be feel lucky to be alive.”
- C. “Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals.”
- D. “Your tracheostomy will be cleaned each time you visit your doctor.”
Correct Answer: C
Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection.
Explanation of why other choices are incorrect:
A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing.
B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately.
D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is
The most significant form of meningitis is:
- A. Bacterial
- B. Septic
- C. Aseptic
- D. Viral
Correct Answer: A
Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
- A. Trim nails short
- B. Keep the neck in midline
- C. Use mild soap
- D. Support and protect bony prominences
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease.
Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area.
Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease.
Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.