Nokea
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
- A. Report the ulcer to the admitting care provider.
- B. Teach the man about STD prevention.
- C. Ask the man if he has a history of syphilis.
- D. Clean the ulcer; reporting is not necessary because an STD is unlikely in a man this age.
Correct Answer: A
Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.
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If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
- A. Expressive aphasia is prominent on clients with right sided weakness
- B. The affected lobe in the patient is the Right lobe
- C. The client will have problems in judging distance and proprioception
- D. Clients orientation to time and space will be much affected NEUROLOGIC NURSING Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.
Correct Answer: B
Rationale: The correct answer is B because the right side weakness indicates a lesion in the left hemisphere of the brain. The brain's motor functions are contralaterally controlled, meaning the left hemisphere controls the right side of the body. Therefore, a right-sided weakness suggests a lesion in the left hemisphere. The other choices are incorrect because expressive aphasia is associated with left hemisphere lesions, judgment of distance and proprioception are more related to parietal lobe lesions, and orientation to time and space is not directly linked to right-sided weakness.
A man‘s blood type is AB and he requires a blood transfusion. To prevent complications of blood incompatibilities, which blood type may the client receive?
- A. Type A or B blood only
- B. Type O blood only
- C. Type AB blood only
- D. Either type A, B, AB, or O blood
Correct Answer: D
Rationale: The correct answer is D because individuals with AB blood type are considered universal recipients, meaning they can receive blood from any blood type without risking complications due to incompatibility. This is because their blood cells have both A and B antigens and do not produce antibodies against either type. Therefore, the client can safely receive blood from types A, B, AB, or O without adverse reactions.
Choices A, B, and C are incorrect because they limit the options for blood transfusion based on the client's AB blood type, which is not necessary given the unique nature of AB blood as universal recipients.
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process helps in identifying any discrepancies or errors in the data. By cross-referencing with other sources, the nurse can verify the correctness of the data.
Rationale:
1. Data validation checks the accuracy of the data by comparing it with external sources.
2. Data interpretation involves analyzing and making sense of the data, not comparing it with other sources.
3. Option A is incorrect because data validation typically comes after data collection and precedes data interpretation.
4. Option B is incorrect as validation does not specifically involve looking for patterns in professional standards.
5. Option D is incorrect because data interpretation focuses on understanding trends and insights from the data, not patterns in professional standards.
The nurse understands that which of the ff. best describes the action of enalapril maleate (Vasotec)?
- A. It decreases levels of angiotensin II
- B. It dilates the arterioles and veins
- C. It adjusts the extracellular volume
- D. It decreases cardiac output
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor.
2. ACE inhibitors like enalapril maleate block the conversion of angiotensin I to angiotensin II.
3. By inhibiting the formation of angiotensin II, enalapril maleate decreases the levels of angiotensin II.
4. Angiotensin II is a potent vasoconstrictor, so decreasing its levels leads to vasodilation and decreased blood pressure.
Summary of why other choices are incorrect:
- Choice B: Enalapril maleate primarily dilates arterioles by decreasing angiotensin II levels, not veins.
- Choice C: Enalapril maleate does not directly adjust extracellular volume; it primarily affects the renin-angiotensin-aldosterone system.
- Choice D: Enalapril maleate
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.