Nokea
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: The correct answer is D: Malnutrition. Malnutrition weakens the immune system, making individuals more susceptible to contracting tuberculosis. A well-nourished individual has a stronger immune response to fight off TB bacteria. Exposure to toxic gases (A), congenital abnormalities (B), and obstruction by tumor (C) do not directly predispose a client to TB. Malnutrition is the key factor as it impairs the immune system's ability to combat the TB bacteria effectively.
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In a 28-year-old female client who is being successfully treated for Cushing syndrome, the nurse would expect a decline in:
- A. serum glucose level.
- B. bone mineralization.
- C. hair loss
- D. menstrual flow.
Correct Answer: D
Rationale: The correct answer is D: menstrual flow. In a 28-year-old female with Cushing syndrome, excess cortisol levels can disrupt the menstrual cycle, leading to irregular or absent periods. Successful treatment for Cushing syndrome aims to restore normal cortisol levels, which should result in the resumption of regular menstrual flow. This indicates that the hormonal balance is improving.
Now, let's analyze the other choices:
A: Serum glucose level - While Cushing syndrome can lead to hyperglycemia, successful treatment would aim to normalize glucose levels, not cause a decline.
B: Bone mineralization - Cushing syndrome can cause osteoporosis due to loss of bone density, but successful treatment would help prevent further bone loss rather than decline.
C: Hair loss - Cushing syndrome can cause hair loss, but successful treatment would not necessarily lead to a decline in hair loss as it may take time for hair to regrow.
Therefore, the correct answer is D as it directly relates to the restoration of hormonal
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient’s daughter runs out of the room and says, “My mother can’t talk. Somebody help!” Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient’s status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: The nurse interprets this as respiratory alkalosis because the patient is likely experiencing hyperventilation, leading to a decrease in CO2 levels and respiratory alkalosis. This is indicated by an increase in pH and a decrease in PaCO2 on arterial blood gas analysis. Metabolic acidosis (choice B) is characterized by low pH and low bicarbonate levels, not seen in this scenario. Respiratory acidosis (choice A) is characterized by high PaCO2 levels and low pH, which is not the case here. Metabolic alkalosis (choice D) is characterized by high pH and high bicarbonate levels, which is not consistent with the patient's presentation.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.