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.
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Pulmonary edema is characterized by:
- A. Elevated left ventricular and-diastolic
- B. Increased hydrostatic pressure
- C. All of the above alterations
- D. A rise in pulmonary venous pressure
Correct Answer: C
Rationale: Rationale:
1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation.
2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema.
3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure.
Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: C
Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
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.