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Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5’3” in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial.
Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.
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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.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction.
Incorrect choices:
B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction.
C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing
Which of the ff instructions should a nurse give a client with non-Hodgkin’s lymphoma who is being treated with radiation and chemotherapy?
- A. Increase fluid intake
- B. Intake low-fat meals
- C. Intake soft, bland foods
- D. Intake food rich in folic acid
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake. This is important for a client undergoing radiation and chemotherapy for non-Hodgkin's lymphoma to prevent dehydration, help flush out toxins, and support kidney function. Increasing fluid intake can also help manage side effects like nausea and vomiting. Choices B, C, and D are incorrect because low-fat meals, soft bland foods, and foods rich in folic acid are not specifically indicated for clients undergoing radiation and chemotherapy for non-Hodgkin's lymphoma.
Which of the following measures will not help correct the patient’s condition
- A. Offer large amount of oral fluid intake to replace fluid lost
- B. Give enteral or parenteral fluid
- C. Frequent oral care
- D. Give small volumes of fluid at frequent interval
Correct Answer: C
Rationale: Step-by-step rationale:
1. Providing oral care does not directly address fluid balance or hydration status.
2. Oral care focuses on maintaining oral hygiene and preventing infections.
3. Choices A, B, and D all involve fluid intake to address dehydration.
4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids.
Summary:
Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.
The nurse should include in the patient’s teaching plan that if the patient does not take the vitamin B12, which one of the following will develop?
- A. Iron deficiency anemia
- B. Sickle cell anemia
- C. Pernicious anemia
- D. Acquired haemolytic anemia
Correct Answer: C
Rationale: The correct answer is C: Pernicious anemia. Vitamin B12 is essential for the production of red blood cells, and its deficiency can lead to pernicious anemia, characterized by decreased red blood cell production. Without adequate vitamin B12, the body cannot properly utilize iron, leading to anemia. Iron deficiency anemia (choice A) is a result of insufficient iron levels, not vitamin B12 deficiency. Sickle cell anemia (choice B) is a genetic disorder affecting hemoglobin, not related to vitamin B12 deficiency. Acquired haemolytic anemia (choice D) is caused by the premature destruction of red blood cells, not by vitamin B12 deficiency.