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Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?
- A. Hearing loss, vertigo, and tinnitus
- B. Nausea, vomiting and pain
- C. Nystagmus, headache and vomiting
- D. Nystagmus, vomiting and pain
Correct Answer: A
Rationale: The correct answer is A: Hearing loss, vertigo, and tinnitus. Meniere's disease is characterized by a triad of symptoms: recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus. Vertigo is a spinning sensation, hearing loss affects the inner ear, and tinnitus is ringing in the ear. Nausea, vomiting, pain, nystagmus, or headache are not typically part of the classic triad of Meniere's disease symptoms. Therefore, option A is the most appropriate choice based on the specific symptomatology associated with Meniere's disease.
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To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
- A. Raise the client’s head
- B. Place the client on a firm mattress
- C. Call the physician
- D. Administer an analgesic to relieve the pain
Correct Answer: C
Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- B. Carcinoma is situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
- D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer: B
Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed.
Step 2: N0 indicates no abnormal regional lymph nodes are involved.
Step 3: M0 signifies no evidence of distant metastasis.
Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report.
Summary:
A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor.
C: Incorrect - TIS already assesses tumor presence, ruling out this option.
D: Incorrect - TIS is not about ascending degrees of distant metastasis.
A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.