Nokea
Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
- A. Rapid progressive muscular atrophy.
- B. Ascending paralysis with ataxia .
- C. Hyperactive deep tendon reflexes
- D. Paresthesia and muscle weakness of upper body.
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.
You may also like to solve these questions
A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?
- A. Encourage the mother to walk to facilitate labor progression.
- B. Administer oxytocin to augment labor.
- C. Prepare for cesarean section.
- D. Encourage relaxation techniques to manage pain.
Correct Answer: A
Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.
A nurse is preparing to assist with a cardiopulmonary exercise stress test for a patient. What action should the nurse prioritize to ensure patient safety during the test?
- A. Administering a beta-blocker medication to the patient before the test
- B. Monitoring the patient's electrocardiogram (ECG) rhythm continuously during the test
- C. Encouraging the patient to consume a heavy meal two hours before the test
- D. Allowing the patient to resume normal activities immediately after the test
Correct Answer: B
Rationale: The most critical action to prioritize for ensuring patient safety during a cardiopulmonary exercise stress test is to monitor the patient's electrocardiogram (ECG) rhythm continuously during the test (Option B). This monitoring allows the healthcare team to promptly detect any abnormal heart rhythms or signs of cardiac distress, enabling timely intervention if necessary. Continuous ECG monitoring is essential during exercise testing as it helps in assessing the heart's response to physical activity and identifying any potential cardiac abnormalities or complications that may arise during the test. By closely monitoring the ECG rhythm, the nurse can ensure the patient's safety and well-being throughout the procedure. Administering a beta-blocker medication before the test (Option A) may be indicated in some cases but is not as crucial as continuous ECG monitoring during the test. Encouraging the patient to consume a heavy meal before the test (Option C) is contraindicated as it can interfere with the accuracy of the results
While preparing the surgical instruments for sterilization, the nurse notices that the autoclave is not reaching the required temperature. What should the nurse do?
- A. Document the issue in the equipment log and continue with sterilization
- B. Adjust the settings on the autoclave to increase the temperature
- C. Notify the sterile processing department and request maintenance
- D. Use an alternative method of sterilization for the instruments
Correct Answer: C
Rationale: It is crucial to ensure that the autoclave is functioning properly to achieve proper sterilization of surgical instruments. If the autoclave is not reaching the required temperature, it signifies a technical issue that needs to be addressed promptly. The nurse should notify the sterile processing department immediately and request maintenance to investigate and resolve the problem. Continuing with sterilization without addressing the temperature issue can compromise the effectiveness of sterilization and pose a risk of infection to patients. Adjusting the settings on the autoclave or using an alternative method of sterilization are not appropriate actions in this situation.
A pregnant woman presents with lower abdominal pain, fever, and vaginal discharge. On examination, cervical motion tenderness and bilateral adnexal tenderness are noted. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: B
Rationale: Pelvic inflammatory disease (PID) is the most likely cause of the symptoms described in the pregnant woman. PID is an infection of the female reproductive organs, typically caused by sexually transmitted bacteria like Chlamydia or Gonorrhea. The classic presentation includes lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, and bilateral adnexal tenderness on examination. This condition can lead to serious complications if not promptly treated, including infertility, ectopic pregnancy, and chronic pelvic pain. Therefore, it is crucial to diagnose and manage PID promptly, especially in pregnant women, to prevent adverse outcomes.
A patient presents with recurrent episodes of deep vein thrombosis (DVT) and pulmonary embolism (PE). Laboratory tests reveal elevated levels of antiphospholipid antibodies (anticardiolipin and lupus anticoagulant). Which of the following conditions is most likely to cause these findings?
- A. Protein C deficiency
- B. Protein S deficiency
- C. Antithrombin III deficiency
- D. Antiphospholipid syndrome
Correct Answer: D
Rationale: Antiphospholipid syndrome is characterized by abnormal antiphospholipid antibodies, which can lead to an increased risk of blood clots such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The two most common antiphospholipid antibodies are anticardiolipin and lupus anticoagulant. Patients with antiphospholipid syndrome can present with recurrent thrombotic events, such as DVT and PE, due to the pro-thrombotic effects of these antibodies. Protein C deficiency, Protein S deficiency, and Antithrombin III deficiency are other causes of hypercoagulability but would not typically present with elevated antiphospholipid antibodies.