Nokea
Which white blood cells are involved in releasing histamine during an allergic reaction?
- A. Basophils
- B. Monocytes
- C. Eosinophils
- D. Neutrophils
Correct Answer: A
Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.
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A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
- A. To identify a life-threatening problem
- B. To establish a database for medical care
- C. To practice respiratory assessment skills
- D. To facilitate the resident’s ability to breathe
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe.
2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention.
3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue.
4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking.
Summary:
- Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking.
- Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database.
- Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation.
- Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D. Asking the patient about usual sleep patterns and the onset of having difficulty resting is the best action for the nurse to take. This allows the nurse to gather more information and assess if there is a possible correlation between the leg cast and the restless sleep. It is important to consider all aspects of the patient's condition and not dismiss any symptoms.
Choice A is incorrect because telling the patient to just focus on the leg and cast disregards the patient's concerns about restless sleep.
Choice B is incorrect as simply documenting the information without further assessment does not address the patient's issue.
Choice C is incorrect as postponing a thorough assessment to the next shift may delay necessary intervention for the patient's sleep problem.
Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
- A. Reassess the patient and situation.
- B. Revise the turning schedule to increase the frequency.
- C. Delegate turning to the nursing assistive personnel.
- D. Apply medication to the area of skin that is broken down.
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan.
B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer.
C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer.
D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.