Nokea
Which of the following is a characteristic symptom of multiple sclerosis (MS)?
- A. Muscle atrophy.
- B. Severe pain.
- C. Vision problems.
- D. Hearing loss.
Correct Answer: C
Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.
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What is a key intervention for a patient with diabetic ketoacidosis (DKA)?
- A. Administering insulin
- B. Administering IV fluids
- C. Administering oral glucose
- D. Administering oral fluids
Correct Answer: A
Rationale: Administering insulin is a crucial intervention for a patient with diabetic ketoacidosis (DKA) because it helps in managing hyperglycemia and ketosis by promoting the uptake of glucose by cells and inhibiting the production of ketones. IV fluids are necessary to correct dehydration and electrolyte imbalances commonly seen in DKA but are not the primary treatment for the condition. Administering oral glucose would exacerbate hyperglycemia in a patient with DKA, while administering oral fluids alone would not effectively address the underlying metabolic disturbances seen in DKA.
A client with diabetes begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.
- B. We can teach your daughter to give the shots so you will not have to do it.
- C. I can arrange to have a home care nurse give you the shots every day.
- D. What is it about giving yourself the insulin shots that bothers you?
Correct Answer: D
Rationale: The correct response is option D because it is an open-ended question that allows the client to express their feelings and concerns. This approach facilitates a therapeutic communication process by encouraging the client to verbalize their thoughts, emotions, and fears related to giving themselves insulin shots. Option A is incorrect as it uses a fear-inducing statement that may not be helpful in addressing the client's emotional needs. Option B assumes involvement of a family member without exploring the client's feelings further. Option C offers a solution without addressing the client's underlying concerns and emotions, potentially overlooking essential aspects of client-centered care.
When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct Answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.
The healthcare provider is assessing a client who is receiving hemodialysis for the first time. Which of the following findings should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Nausea and vomiting.
- C. Fatigue.
- D. Headache.
Correct Answer: B
Rationale: Nausea and vomiting are critical symptoms that should be reported immediately when a client is receiving hemodialysis for the first time. These symptoms could indicate a severe complication, such as hypotension, infection, electrolyte imbalance, or other adverse reactions to the procedure. It is essential to address these symptoms promptly to prevent further complications or harm to the client. Choices A, C, and D are not immediate concerns during the first hemodialysis session and can be addressed appropriately after addressing the urgent issue of nausea and vomiting.
Which of the following is a key symptom of hyperthyroidism?
- A. Weight loss.
- B. Weight gain.
- C. Tachycardia.
- D. Dry skin.
Correct Answer: A
Rationale: The correct answer is weight loss. In hyperthyroidism, there is an excess production of thyroid hormones leading to an increased metabolic rate. This increased metabolism can result in weight loss despite normal or increased appetite. Choice B (Weight gain) is more commonly associated with hypothyroidism where the metabolic rate is decreased. Choice C (Tachycardia) is another common symptom of hyperthyroidism due to the effects of thyroid hormones on the heart, causing an increased heart rate. Choice D (Dry skin) is not a typical symptom of hyperthyroidism; instead, it is more commonly associated with hypothyroidism.