Nokea
Which of the following health teaching concern for the nurse as discharged plan for suicidal patient who had been taking tricyclic antidepressant drugs for 2 weeks and now ready to go home?
- A. The nurse will need to include teaching regarding signs of narcoleptic malignant syndrome.
- B. The patient will need regular laboratory work to monitor therapeutic drug levels.
- C. The nurse will evaluate the risk for suicide by overdose of tricyclic antidepressant.
- D. The patient may need a prescription for Benadryl to use for side effects.
Correct Answer: C
Rationale: When discharging a suicidal patient who has been taking tricyclic antidepressant drugs, it is crucial for the nurse to evaluate the risk for suicide by overdose of the medication. Tricyclic antidepressants have a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose can be quite small. This makes them particularly dangerous in cases of overdose, as they can lead to severe toxic effects, including cardiac arrhythmias, seizures, and death.
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What symptom is an INDICATOR of cranial nerve involvement?
- A. Difficulty of speaking and chewing.
- B. Loss of pain sensation
- C. Spastic paralysis of the extremities
- D. Forgetfulness and syncope
Correct Answer: A
Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.
A woman in active labor is diagnosed with an obstetric emergency requiring immediate delivery. What is the priority nursing action?
- A. Notifying the healthcare provider
- B. Preparing the delivery room for immediate birth
- C. Administering intravenous fluids rapidly
- D. Facilitating continuous fetal monitoring
Correct Answer: B
Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.
A patient receiving palliative care for end-stage liver disease develops hepatic encephalopathy, presenting with confusion and altered mental status. What intervention should the palliative nurse prioritize to manage the patient's symptoms?
- A. Administer lactulose or other ammonia-lowering agents to reduce ammonia levels.
- B. Initiate intravenous fluid therapy to correct electrolyte imbalances.
- C. Refer the patient to a neurologist for evaluation and treatment of encephalopathy.
- D. Prescribe sedative medications to promote sleep and reduce agitation.
Correct Answer: A
Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.
Lillian asks the nurse the cause of this ailment. Which of the following would the nurse explain as predisposing factors of mastitis? (Select all that apply) I. Milk stasis II. Nipple trauma III. Using alcohol in cleaning nipples IV. Baby 's sitting position
- A. II and IV
- B. I and II
- C. I and IV
- D. II and III
Correct Answer: B
Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.
A pregnant woman presents with vaginal bleeding and passage of tissue at 10 weeks gestation. On examination, the cervix is dilated, and products of conception are visualized in the cervical os. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Threatened abortion
- C. Placenta previa
- D. Complete abortion
Correct Answer: D
Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.