Nokea
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed helps to promote venous drainage from the brain, which can help reduce intracranial pressure (ICP). By positioning the patient with the head of the bed at a 30-45 degree angle, it can facilitate the circulation of cerebrospinal fluid and blood, thus preventing a further increase in ICP. This intervention is a crucial aspect of managing patients with increased ICP and can help improve their overall neurological status.
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When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.
The nurse understands that which of the ff. best describes the action of propanolol (Inderal)?
- A. It increases heart rate
- B. It decreases fluid volume
- C. It decreases cardiac output
- D. It increases cardiac contractility
Correct Answer: C
Rationale: Propranolol (Inderal) is a non-selective beta-blocker that works by blocking beta receptors in the heart and blood vessels. By blocking these receptors, propranolol decreases the effects of adrenaline, leading to a decrease in heart rate, blood pressure, and cardiac output. This results in a reduction in the workload of the heart, making it an effective medication for conditions such as hypertension, angina, and certain types of arrhythmias. Overall, the action of propranolol leads to a decrease in cardiac output, contrary to the options that suggest an increase in heart rate, fluid volume, or cardiac contractility.
Which food should be avoided by the patient on a low-sodium diet?
- A. Apples
- B. Chicken
- C. Cheese
- D. Broccoli
Correct Answer: C
Rationale: Cheese is high in sodium and should be avoided by patients on a low-sodium diet. It is a common source of hidden sodium in many diets. Other high-sodium foods that should be limited or avoided include processed meats, canned soups, processed snacks, and condiments. Patients should focus on eating fresh fruits and vegetables, lean proteins like chicken (with no added salt), and whole grains to maintain a low-sodium diet.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: For male clients over age 50, early identification of prostate cancer involves a combination of regular digital rectal examination and PSA test. The digital rectal examination allows a healthcare provider to manually assess the size, shape, and consistency of the prostate gland, looking for any abnormalities such as nodules or hard areas that may indicate prostate cancer. The PSA test measures the level of prostate-specific antigen in the blood, with elevated levels potentially signaling the presence of prostate cancer. Yearly screening using both these methods increases the chances of early detection and optimal management of prostate cancer in older male clients. Regular monitoring helps in identifying the disease at an earlier, more treatable stage, improving outcomes and prognosis.
With pulmonary edema, there is usually an alteration in:
- A. Afterload
- B. Preload
- C. Contractility
- D. All of the above
Correct Answer: D
Rationale: Pulmonary edema is characterized by the accumulation of excess fluid in the lungs, which can lead to impaired gas exchange and respiratory distress. In the presence of pulmonary edema, there is usually an alteration in all three factors mentioned: afterload, preload, and contractility.