Nokea
Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.
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When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?
- A. Antacids
- B. Vitamins with irons
- C. Acetaminophen preparations
- D. Salicylate preparations
Correct Answer: D
Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
- A. there is no insulin available for the state of hyperglycemia
- B. the type II diabetic has no protein of fat reserves
- C. there is no sufficient insulin to prevent the breakdown of protein and fatty acid for metabolic needs
- D. there is insufficient serum glucose concentrations
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer):
- In type II DM, there is some insulin present but it is insufficient to meet the body's needs.
- Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy.
- This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA).
- Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs.
Summary of other choices:
- Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient.
- Choice B is incorrect as type II diabetics do have fat and protein reserves.
- Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
- A. Allow her to ambulate unassisted, to encourage positive self-esteem.
- B. Ask her to demonstrate her ability to ambulate.
- C. Explain that someone will assist her as long as she is in the rehabilitation facility.
- D. Ask another staff member to help ambulate the patient the first time.
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety.
Incorrect responses:
A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety.
C: Explaining that assistance will always be available may not address the immediate need for assessment and safety.
D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.