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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: Dyspnea on exertion is often identified as the earliest symptom of heart failure in many older clients. This symptom occurs due to the heart's inability to pump blood efficiently, leading to a buildup of fluid in the lungs. As a result, individuals may experience shortness of breath when engaging in physical activity or even at rest. Monitoring for dyspnea on exertion can aid in the early detection and management of heart failure in older clients. Other symptoms, such as increased urine output, swollen joints, and nausea/vomiting, may also occur in heart failure, but dyspnea on exertion is typically considered one of the earliest signs to manifest.
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Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?
- A. BUN and creatinine
- B. Hgb and Hct
- C. ABG
- D. Serum potassium
Correct Answer: C
Rationale: Patients with Guillain-Barre Syndrome are at risk for respiratory complications due to muscle weakness and paralysis, particularly affecting the respiratory muscles. Monitoring arterial blood gas (ABG) levels is crucial in assessing respiratory function and detecting respiratory failure early in these patients. ABG levels provide information on oxygenation, ventilation, and acid-base balance, which are essential parameters to monitor closely in patients with Guillain-Barre Syndrome to prevent respiratory compromise and potential respiratory failure. Regular ABG monitoring helps healthcare providers intervene promptly if respiratory abnormalities develop, ensuring timely treatment and preventing serious complications.
A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?
- A. Identify the problem with a nursing diagnosis of impaired communication related to the diagnosis of cancer
- B. Set a patient outcome that the patient will verbalize his concerns about his diagnosis
- C. Ask the patient whether he is worried about future sexual functioning
- D. Say, "You seem quiet. Are you feeling concerned about your diagnosis or treatment?"
Correct Answer: D
Rationale: Option D is the most appropriate action in this scenario because it demonstrates empathy and opens the door for the patient to express his concerns. By acknowledging the patient's withdrawn behavior and directly inquiring about his feelings regarding the diagnosis or treatment, the nurse creates an opportunity for the patient to share his thoughts and concerns. This open-ended question allows the patient to express himself without any assumptions or judgments. It shows that the nurse is attentive, supportive, and willing to listen to the patient's emotional needs during this challenging time.
A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?
- A. The client sees letters at 20 feet that others can read at 40 feet
- B. The client sees letters at 40 feet that others can read at 20 feet
- C. The client sees colors at 20 feet that others can see at 40 feet
- D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A
Rationale: In the Snellen eye chart test, the first number (20) represents the distance at which the client is standing from the chart, while the second number (40) represents the distance at which a person with normal vision can read the same line on the chart. A person with 20/40 vision can see letters at 20 feet that a person with normal vision can see at 40 feet. This means that the client's vision is below the standard for normal vision, indicating that they may need corrective lenses to improve their visual acuity.
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.
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.