Nokea
Which of the ff is the result of central nervous system manifestations?
- A. Congestive Heart Failure c.Valve damage
- B. Chorea
- C. Pericarditis
Correct Answer: B
Rationale: Chorea is the result of central nervous system manifestations. Chorea is a movement disorder characterized by involuntary, brief, random, and irregular muscle movements that are often seen in neurological conditions such as Huntington's disease. The central nervous system is responsible for controlling and coordinating movements, so any dysfunction in the central nervous system can lead to movement disorders like chorea. Therefore, chorea is directly related to central nervous system manifestations, unlike congestive heart failure, valve damage, or pericarditis which are primarily related to cardiovascular issues.
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During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
- A. Recommending that the client discontinue chemotherapy
- B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
- C. monitoring the client's platelet and leukocyte counts
- D. Checking regularly for signs and symptoms of stomatitis
Correct Answer: B
Rationale: Providing a solution of hydrogen peroxide and water for use as a mouth rinse is most likely to decrease the pain of stomatitis. Stomatitis is inflammation of the oral mucous membranes and can be quite painful for oncology clients undergoing chemotherapy. Using a solution of hydrogen peroxide and water as a mouth rinse can help reduce the risk of infection and promote healing of the mucous membranes, thereby decreasing the pain associated with stomatitis. This intervention helps to maintain oral hygiene and prevent further complications, making it an effective way to manage the client's symptoms while undergoing chemotherapy. It is important to note that discontinuing chemotherapy would not be a recommended intervention as it is the primary treatment for the client's cancer. Monitoring platelet and leukocyte counts and checking for signs and symptoms of stomatitis are important aspects of care, but providing a mouth rinse would directly address the pain and discomfort experienced by the client.
A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
- A. Deficient volume related to osmotic diuresis
- B. Decreased cardiac output related to elevated heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.
Parents have a concern that their child is depressed. The nurse relates that which characteristic best describes children with depression?
- A. Increased range of affective response
- B. Preoccupation with need to perform well in school
- C. Change in appetite, resulting in weight loss or gain
- D. Tendency to prefer play instead of schoolwork
Correct Answer: C
Rationale: Change in appetite, resulting in weight loss or gain, is a common characteristic seen in children with depression. Some children may experience a significant decrease in appetite, leading to weight loss, while others may have an increased appetite, resulting in weight gain. This change in eating habits is often a noticeable sign that may indicate the presence of depression in children. It is important for parents and caregivers to be aware of any significant changes in a child's eating patterns and behavior, as it could be a potential indicator of underlying mental health issues such as depression.
Which blood gas analyses are most indicative of respiratory acidosis?
- A. pH = 7.22, PCO2 = 55 mmHg, HCO3 = 30 mEq/L.
- B. pH = 7.28, PCO2 = 45 mmHg, HCO3 = 15 mEq/L.
- C. pH = 7.34, PCO2 = 35 mmHg, HCO3 = 25 mEq/L.
- D. pH = 7.40, PCO2 = 25 mmHg, HCO3 = 30 mEq/L.
Correct Answer: A
Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.
Phenylketonuria (PKU) is a genetic disease that results in the body's inability to correctly metabolize:
- A. glucose.
- B. phenylalanine.
- C. phenylketones.
- D. thyroxine.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder that affects the body's ability to metabolize the amino acid phenylalanine. Individuals with PKU lack an enzyme called phenylalanine hydroxylase, which results in the buildup of phenylalanine in the body. If untreated, high levels of phenylalanine can lead to intellectual disabilities, seizures, and other serious health problems. Therefore, individuals with PKU need to follow a special diet low in phenylalanine to prevent these complications.