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Which of the ff. statements, if made by a patient with hypertension, indicates to a nurse a need for more teaching?
- A. “High BP may affect the kidneys and eyes.”
- B. “Most people with hypertension watch their diet.”
- C. “Medication will no longer be needed when I feel better.”
- D. “Many people do not know when their BP is high.”
Correct Answer: C
Rationale: Step-by-step rationale:
1. Statement C indicates a misunderstanding that medication can be stopped when feeling better, which is incorrect.
2. Hypertension is a chronic condition that often requires lifelong medication.
3. This demonstrates a lack of understanding regarding the necessity of long-term management.
4. Statements A, B, and D show knowledge about hypertension's effects, dietary management, and awareness, respectively.
Summary: Statement C is incorrect as it suggests stopping medication, while statements A, B, and D show accurate understanding of hypertension.
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When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function.
Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.
Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:
- A. Cell division or mitosis during the M phase of the cell cycle.
- B. Normal cellular processes during the S phase of the cell cycle.
- C. The chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle-nonspecific).
- D. One or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle- nonspecific).
Correct Answer: D
Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
- A. Assess the involved extremity for color and temperature
- B. Check for capillary refill
- C. Evaluate pulse rate
- D. Do all of the above
Correct Answer: D
Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: The correct answer is A: Confusion or delirium can be a defense against further stress. This is because providing new information slowly and in small amounts can help prevent overwhelming Mr. Reyes, who is already confused. This approach allows him to process and understand the information more effectively without adding to his stress levels.
Choices B, C, and D are incorrect:
B: Destruction of brain cells has occurred, interrupting mental activity - This is not the most appropriate explanation as it assumes irreversible damage to the brain, which is not mentioned in the question.
C: Teaching based on information progressing from the simple to the complex - While this may be a valid teaching strategy in general, it does not address Mr. Reyes' specific state of confusion and the need to reduce stress.
D: A minimum of information should be given, since he is unaware of surrounding - This choice does not address the underlying reason for providing information slowly, which is to manage stress and confusion, rather than solely focusing on the
A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
- A. A hemolytic reaction to mismatched blood
- B. A hemolytic reaction to Rh-incompatible blood
- C. A hemolytic allergic reaction caused by bacterial contamination of donor blood
- D. None of the above
Correct Answer: A
Rationale: The correct answer is A: A hemolytic reaction to mismatched blood. Chills, dyspnea, and urticaria are indicative of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks the donor's red blood cells. This can lead to various symptoms, including fever, chills, difficulty breathing, and hives. This type of reaction is most commonly seen with mismatched blood types.
Option B (A hemolytic reaction to Rh-incompatible blood) is incorrect because Rh incompatibility typically leads to hemolytic disease of the newborn, not an immediate transfusion reaction. Option C (A hemolytic allergic reaction caused by bacterial contamination of donor blood) is incorrect as bacterial contamination would present with symptoms such as fever and sepsis, not chills, dyspnea, and urticaria. Option D (None of the above) is incorrect as the symptoms presented align with a hemolytic transfusion reaction.