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Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.
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Which of the following responses indicates sympathetic nervous system function?
- A. Tachycardia, dilated pupils
- B. Hypoglycaemia, headache
- C. Increased peristalsis, abdominal cramping
- D. Pupil constriction, bronchoconstriction
Correct Answer: A
Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action.
Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
The normal life expectancy for 50% of patients ith amyotropic lateral sclerosis (ALS) is:
- A. 3 years
- B. 10 years
- C. 5 years
- D. 20 years
Correct Answer: C
Rationale: The correct answer is C (5 years) because ALS is a progressive and fatal neurodegenerative disease. The median life expectancy for most ALS patients is around 3-5 years from the onset of symptoms. Choice A (3 years) is too short for 50% of patients. Choice B (10 years) and Choice D (20 years) are longer than the typical life expectancy for ALS patients, making them incorrect. The progression of ALS varies among individuals, but statistically, 50% of patients would be expected to live around 5 years after diagnosis.
A patient asks how to avoid lung cancer. The following are risk factors, except:
- A. Exposure to passive smoke
- B. Crowded living conditions
- C. Air pollution
- D. Diet low in fruits and vegetables
Correct Answer: B
Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer.
Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer.
Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk.
Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Bowel management
- C. Sexual activity
- D. . All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.