Nokea
Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?
- A. "I don't have to worry about changing my
- B. "I don't have to worry if I get a strep. throat diet."
- C. I need to work on managing stress in life."
Correct Answer: B
Rationale: Option B, "I don't have to worry if I get a strep throat," shows that the client does not understand the cause of exacerbation of systemic lupus erythematosus (SLE). Strep throat can trigger SLE exacerbations as infections are known to worsen autoimmune diseases like lupus. This statement indicates a lack of awareness regarding the potential impact of infections on SLE symptoms. Option A and C show a better understanding as they address the importance of diet and stress management, which are significant factors that can influence the course of SLE.
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Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: For a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS), the correct statement is to administer 6L of IV fluid over the first 24 hours (option B). The management of HHNS focuses on correcting dehydration and hyperglycemia. The initial fluid resuscitation in HHNS aims to address the profound dehydration that occurs due to osmotic diuresis from hyperglycemia. The recommended rate is to administer 1 to 1.5 L/hour of IV fluid until the patient is hemodynamically stable and urine output is adequate. Administering fluid rapidly helps to address the hypovolemia and prevent complications associated with shock. Administering fluid too slowly may delay the correction of dehydration and lead to further complications.
Which of the ff. is a normal hemoglobin value?
- A. 38% to 48%
- B. 48 to 54 mg%
- C. 12 to 18 g/100mL
- D. 27 to 36 g/dL
Correct Answer: C
Rationale: The normal hemoglobin values are typically expressed in grams per deciliter (g/dL) or grams per 100 milliliters (g/100mL) of blood. The range of 12 to 18 g/100mL is considered the normal range for hemoglobin levels in adults. Hemoglobin values outside of this range may indicate various health conditions such as anemia or polycythemia. Option A (38% to 48%) is a range for hematocrit, not hemoglobin. Option B (48 to 54 mg%) and Option D (27 to 36 g/dL) are not within the standard normal range for hemoglobin levels.
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
- A. "The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!"
- B. "His stroke has made him less inhibited. We'll see if we can find a male assistant to help him."
- C. "We have to take care of all patients equally, even the dirty old men."
- D. "He didn't mean anything by it, just ignore it."
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
The stump of the umbilical cord usually separates in how many days?
- A. 3
- B. 10 to 14
- C. 16 to 20
- D. 28
Correct Answer: B
Rationale: The stump of the umbilical cord usually separates from the baby's belly button within 10 to 14 days after birth. During this time, it is important to keep the area clean and dry to prevent infection. Once the stump falls off, a small open wound may be left behind, which should also be kept clean and dry until it completely heals. It is normal for a small amount of blood or discharge to be present during this process, but if there are signs of infection such as redness, swelling, or foul odor, it is important to contact a healthcare provider for further evaluation and treatment.
Blood cells are formed in the:
- A. Arterioles
- B. Lymphoid tissue
- C. Bone marrow
- D. Muscle tissue
Correct Answer: C
Rationale: Blood cells are formed in the bone marrow, which is a soft tissue found in the center of most bones in the body. The process of blood cell formation is known as hematopoiesis. Bone marrow contains stem cells that can develop into different types of blood cells, including red blood cells, white blood cells, and platelets. These blood cells play essential roles in carrying oxygen, fighting infections, and assisting in blood clotting. While the other choices listed (arterioles, lymphoid tissue, and muscle tissue) have important functions in the body, blood cell formation specifically occurs primarily in the bone marrow.