Nokea
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the side with support to the back, pillows for body alignment, and a washcloth to slightly curl the fingers helps prevent contractures, aids in maintaining proper alignment, and provides support for the affected side. This position also promotes optimal blood flow and prevents pressure sores.
Choice A is incorrect because tightly holding a rolled washcloth can restrict blood flow and cause discomfort. Choice C is incorrect as lying on the back with pillows under the head and knees does not address the specific needs of right-sided paralysis. Choice D is incorrect as trochanter rolls may not provide adequate support for the paralyzed side, and no pillows can lead to pressure sores and discomfort.
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Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?
- A. administer morphine sulfate as ordered
- B. obtain daily weights
- C. maintain Aling Loida on high calorie, high protein diet
- D. place her on supine position
Correct Answer: A
Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being.
Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
60 year-old Mrs. Torres arrived just in time for her doctor’s appointment. She complains of pain and stiffness in her back. She is suspected of having osteoporosis. Nurse Ariane will inform Mrs. Torres that the primary complication of osteoporosis is:
- A. Increased trabeculae
- B. poor posture
- C. chronic pain
- D. fractures
Correct Answer: D
Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
- A. Fluoxymesterone (Halotestin)
- B. Fluorouracil (5-fluorouracil, 5 FU
- C. Tamoxifen (Nolvadex) [Fluoroplex])
- D. Megestrol (Megace)
Correct Answer: B
Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes.
Summary of other choices:
A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer.
C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer.
D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.
A patient is admitted with a 2-month history of fatigue, SOB, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune haemolytic anemia. On reviewing the laboratory results, the nurse notes which of the following that confirms this diagnosis?
- A. RBC fragments
- B. Microcytic, hypochromic RBCs
- C. Macrocytic, normochromic RBCs
- D. Hemoglobin molecules
Correct Answer: A
Rationale: The correct answer is A: RBC fragments. In idiopathic autoimmune hemolytic anemia, the immune system attacks and destroys red blood cells, leading to hemolysis. The presence of RBC fragments in the blood smear confirms this diagnosis as it indicates mechanical damage to RBCs.
Explanation:
1. RBC fragments (schistocytes) are a hallmark of hemolysis, seen in conditions like autoimmune hemolytic anemia.
2. Microcytic, hypochromic RBCs (Choice B) are typically seen in iron deficiency anemia, not autoimmune hemolytic anemia.
3. Macrocytic, normochromic RBCs (Choice C) are characteristic of megaloblastic anemias like vitamin B12 deficiency, not autoimmune hemolytic anemia.
4. Hemoglobin molecules (Choice D) are not directly indicative of autoimmune hemolytic anemia; the presence of free hemoglobin in the blood would suggest intrav