Nokea
Which of the ff should a client with auto immune disorder be advised to avoid?
- A. Resting during the periods of severe exacerbation
- B. Regular exercise during the periods of remission
- C. Being in crowds during the periods of immunosuppression
- D. Humid environment during the periods of remission
Correct Answer: C
Rationale: The correct answer is C: Being in crowds during the periods of immunosuppression. Clients with autoimmune disorders have compromised immune systems, making them more susceptible to infections. Being in crowds increases the risk of exposure to various pathogens, potentially leading to infections. Avoiding crowds during periods of immunosuppression helps minimize the risk of infections.
A: Resting during the periods of severe exacerbation is important for managing symptoms and conserving energy, but it is not specifically related to avoiding triggers for autoimmune disorders.
B: Regular exercise during the periods of remission is beneficial for overall health and can help manage autoimmune disorders, as long as it is appropriate and not excessive.
D: Humid environments during the periods of remission do not directly impact autoimmune disorders unless the individual has a specific sensitivity to humidity.
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A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery.
Incorrect choices:
B: Hiccups - Hiccups are not a common side effect of Ketamine administration.
C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions.
D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids.
Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis.
A: Hyperventilation would lead to respiratory alkalosis, not acidosis.
B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis.
D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis.
In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.
A client asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
- A. multiple drugs allow reduced levels of drugs to be given
- B. multiple drugs reduce undesirable drug side-effect
- C. multiple drugs potentiate the action fo the drugs
- D. multiple drugs reduce development of resistant strains of the bacteria
Correct Answer: D
Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time.
Explanation for other choices:
A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs.
B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains.
C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own.
Incorrect Answers:
A: Purplish stools - This is not a common side effect of lymphangiography.
B: Redness of the upper part of the feet - Redness is not typically associated with this procedure.
D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.