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Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
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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.
To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis.
Incorrect choices:
B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly.
C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness.
D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.
The nurse assesses for the characteristic movement of Parkinson’s disease which is a (n):
- A. Exaggerated muscle flaccidity that leads to frequent falls
- B. Hyperextension of the back and neck that alters normal movements
- C. Pronation- supination of the hand and forearm that interferes with normal hand activities
- D. Combination of all of the above
Correct Answer: C
Rationale: The correct answer is C because pronation-supination of the hand and forearm is a characteristic movement in Parkinson's disease called "pill-rolling tremor." This movement interferes with normal hand activities due to involuntary shaking.
A is incorrect because exaggerated muscle flaccidity does not lead to frequent falls in Parkinson's disease. B is incorrect as hyperextension of the back and neck is not a characteristic movement of Parkinson's disease. D is incorrect as it combines all options, which is not accurate.
Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
- A. Abnormal distribution of body hair
- B. Lifetime dependency on hormone replacement
- C. The need to drink many fluids to replace those lost
- D. The need to undergo repeat surgical procedures
Correct Answer: B
Rationale: The correct answer is B: Lifetime dependency on hormone replacement. After hypophysectomy, the pituitary gland is removed, leading to a deficiency in essential hormones. Patients will need lifelong hormone replacement therapy to maintain normal body functions. This is crucial for regulating metabolism, growth, reproduction, and stress response. Choices A, C, and D are incorrect because abnormal distribution of body hair, increased fluid intake, and repeat surgical procedures are not typically associated with hypophysectomy. It is essential to focus on the long-term management of hormone replacement therapy to ensure the patient's overall health and well-being.
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.