Nokea
Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Correct Answer: D - Lubricating eye drops
Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.
Summary of Incorrect Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.
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Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient’s accomplishments without a time
- A. restriction.
- B. It is a realistic statement predicting any negative responses to treatments.
- C. It is a broad statement describing a desired change in a patient’s behavior.
- D. It is a measurable change in a patient’s physical state.
Correct Answer: D
Rationale: Step 1: A goal should be measurable to track progress effectively.
Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome.
Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound.
Step 4: Other choices lack the specificity and measurability required for a clear goal.
Step 5: Choice A talks about restriction, which is not directly related to understanding a goal.
Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal.
Step 7: Choice C is vague and lacks the specificity of a measurable outcome.
A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:
- A. Less than 136mOsm/kg
- B. Greater than 408mOsm/kg
- C. 280 to 295mOsm/kg
- D. 350 to 544mOsm/kg
Correct Answer: C
Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.
A 25-year old with hepatitis may be anicteric and symptomless. In the early part of the hepatic inflammatory disorder, the most likely symptom/sign is:
- A. dark urine
- B. occult blood in stools
- C. ascites
- D. anorexia
Correct Answer: D
Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.
The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?
- A. Joint pain following administration of the medication
- B. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client
- C. A decrease in muscle strength within 30 to 60 seconds following administration of the medication.
- D. An increase in muscle strength within 30 to 60 seconds following administration of the medication
Correct Answer: C
Rationale: The correct answer is C because in myasthenia gravis, which is characterized by muscle weakness and fatigue, the administration of edrophonium will temporarily improve muscle strength due to increased availability of acetylcholine at the neuromuscular junction. This improvement should be noted within 30 to 60 seconds after the administration of the medication.
Choice A is incorrect because joint pain is not a typical response to edrophonium in the context of myasthenia gravis.
Choice B is incorrect because feelings of faintness, dizziness, hypotension, and flushing are more indicative of a cholinergic crisis, which occurs when too much edrophonium is administered.
Choice D is incorrect because an increase in muscle strength post-edrophonium administration would not be expected in a client with myasthenia gravis.
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. “It an be caused by chronic infection of the urinary tract.”
- B. “It was caused by your chronic cigarette smoking.”
- C. “As you age, hormonal imbalances are the more likey cause of your disease.”
- D. “Chronic obstruction of the bladder due to stone can cause BPH.”
Correct Answer: C
Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males.
Explanation of other choices:
A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency.
B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms.
D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.