Nokea
Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hypertrophied tonsils
- C. Hemorrhage in the tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The correct answer is A: White patches on the tonsils. Group A streptococci infection commonly presents with exudative tonsillitis, characterized by the presence of white patches or pus on the tonsils. This is due to the inflammatory response triggered by the bacteria. Hypertrophied tonsils (B), hemorrhage in the tonsils (C), and bleeding in the tonsils (D) are less likely to be visual signs of a streptococcal infection and are more indicative of other conditions or complications. Therefore, white patches on the tonsils are the most specific visual sign associated with group A streptococci tonsillar infection.
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For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: The correct answer is D: Hypovolemia and shock.
Rationale:
1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms.
2. These signs indicate inadequate perfusion due to reduced blood volume.
3. Hypovolemia can progress to shock if not addressed promptly.
Summary:
A: Compression of blood vessels is not directly related to low blood volume.
B: Increasing circulating blood volume would not occur in a client with low blood volume.
C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
- A. Malignant
- B. Non-malignant
- C. Benign
- D. B and C
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- A. Romberg test
- B. Caloric test
- C. Otoscopic examination
- D. Whisper voice test
Correct Answer: D
Rationale: The correct answer is D: Whisper voice test. This test is used as an initial screening for hearing loss because it is simple, quick, and easily administered by a nurse. The nurse would whisper words or numbers at a specific distance from the patient to assess their ability to hear and repeat the whispered sounds accurately. This test provides a quick indication of potential hearing impairment.
The other choices are incorrect:
A: Romberg test assesses balance and not hearing.
B: Caloric test evaluates the vestibular system, not hearing.
C: Otoscopic examination is used to examine the ear canal and tympanic membrane, not to screen for hearing loss.
. A client is prescribed prednisone (Deltasone) daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
- A. Taking the drug at the same time every day establishes a regular routine, reducing the risk of forgetting a dose.
- B. Prednisone has a longer half-life with morning administration, making it more effective.
- C. Morning administration of prednisone mimics the body’s natural corticosteroid secretion pattern.
- D. Prednisone is best absorbed when taken on an empty stomach first thing in the morning.
Correct Answer: C
Rationale: The correct answer is C because morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Cortisol, a natural corticosteroid, is typically highest in the morning and decreases throughout the day. By taking prednisone in the morning, the client aligns the drug's peak concentration with the body's natural cortisol levels, optimizing its therapeutic effects.
Choice A is incorrect because while taking the drug at the same time daily is important for consistency, it does not specifically address the rationale for morning administration. Choice B is incorrect as the effectiveness of prednisone is not solely dependent on its half-life but also on alignment with the body's natural rhythm. Choice D is also incorrect as prednisone can be taken with food and does not necessarily require an empty stomach for optimal absorption.
The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?
- A. "You will be put to sleep before the needle Is inserted."
- B. "The test will take several hours."
- C. "You may fee! a burning sensation when the dye is injected."
- D. "There will be no complications."
Correct Answer: C
Rationale: The correct answer is C: "You may feel a burning sensation when the dye is injected." This is important preprocedure teaching for carotid angiography because it prepares the patient for a common sensation during the procedure, helping to manage their expectations and reduce anxiety. This information is crucial for informed consent.
Choice A is incorrect because carotid angiography is usually done under local anesthesia, not general anesthesia. Choice B is incorrect as carotid angiography typically takes about 1-2 hours, not several hours. Choice D is incorrect because all medical procedures, including carotid angiography, carry potential risks and complications, which should be discussed with the patient.