Nokea
Your client has superior vena cava syndrome. The client's wife asks you what this is. How should you respond to the client's wife? You should explain that superior vena cava syndrome is:
- A. The compression of the renal medulla.
- B. Syncope and dizziness of unknown origin.
- C. Pressure on the vena cava which is a major vein in the body.
- D. Pressure on the vena cava which is the largest artery in the body.
Correct Answer: C
Rationale: Superior vena cava syndrome is caused by compression of the superior vena cava, a major vein, leading to symptoms like swelling and shortness of breath.
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Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply.
- A. Irritability
- B. Hoarse cry
- C. Bradycardia
- D. Constipation
- E. Fused fontanels
- F. Excessive sleeping
Correct Answer: B,C,D,F
Rationale: The infant with congenital hypothyroidism may display the following signs: skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, bradycardia, and a distended abdomen. Other signs and symptoms include prolonged jaundice, lethargy, constipation, feeding problems, coldness to touch, umbilical hernia, hoarse cry, and excessive sleeping.
Which of the following is not considered one of the 'Ten Rights of Medication Administration'?
- A. The 'right' verification
- B. The 'right' to refuse
- C. The 'right' documentation
- D. The 'right' client education
Correct Answer: A
Rationale: The Ten Rights of Medication Administration include right patient, drug, dose, route, time, documentation, reason, response, refusal, and education. 'Right verification' is not a standard right.
The nurse teaches a pregnant client to perform Kegel exercises. Which statement by the client indicates an understanding of the purpose of these types of exercises?
- A. The exercises will help reduce backache.
- B. The exercises will help prevent ankle edema.
- C. The exercises will help strengthen the pelvic floor.
- D. The exercises will help prevent urinary tract infections.
Correct Answer: C
Rationale: Kegel exercises assist in strengthening the pelvic floor (pubococcygeal muscle). Pelvic tilt exercises help reduce backaches. Leg elevation assists in preventing ankle edema. Instructing a client to drink 8 ounces of fluids 6 times a day helps prevent urinary tract infections.
A client with a diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse should teach the client to take the medication:
- A. On an empty stomach.
- B. With meals to reduce side effects.
- C. At bedtime to promote sleep.
- D. As needed for muscle weakness.
Correct Answer: B
Rationale: Pyridostigmine should be taken with food to reduce gastrointestinal side effects like nausea.
The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?
- A. 1 hour
- B. 2 to 3 hours
- C. 4 to 12 hours
- D. 16 to 24 hours
Correct Answer: C
Rationale: NPH is an intermediate-acting insulin with a peak time in 4 to 12 hours. The remaining options describe periods of time that are either too short or too long.