SET 1 Flashcards
While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply.
A. Abdominal respirations B. Irregular breathing rate C. Inspiratory grunt D. Increased heart rate with crying E. Nasal flaring F. Cyanosis G. Asymmetric chest movement
Correct Answers: C, E, F, & G
Option C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound.
Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress.
Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream.
Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress.
Option A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing.
Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds).
Option D: An increase in heart rate is normal for an infant during activity (including crying). Fluctuations in heart rate follow the changes in the newborn’s behavioral state – crying, movement, or wakefulness corresponds to an increase in heart rate.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications.
- Have the client empty bladder
- Place the call bell within reach
- Raise the side rails on the bed
- Instruct the client to remain in bed
Correct order is shown above. (1,4.3,2)
- Have the client empty the bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. If the client does not have a catheter, it is important to empty the bladder before receiving preoperative medications to prevent bladder injury (especially in pelvic surgeries). Else, a straight catheter or an indwelling catheter may be ordered to ensure the bladder is empty.
- Instruct the client to remain in bed. Preoperative medications can cause drowsiness and lightheadedness which may put the client at risk for injury.
- Raise the side rails on the bed. Raising the side rails on the bed helps prevent accidental falls and injury when the client decides to get out of the bed without assistance.
- Place the call bell within reach. Call bells should always be within the reach of a client.
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in the blanks.
Answer: Gravida ____ para _______
Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
Which individual is at the greatest risk for developing hypertension?
A. 45-year-old African-American attorney
B. 60-year-old Asian-American shop owner
C. 40-year-old Caucasian nurse
D. 55-year-old Hispanic teacher
Correct Answer: A: 45-year-old African American attorney
Option A: African-Americans develop high blood pressure at younger ages than other groups in the US. Researchers have uncovered that African-Americans respond differently to hypertensive drugs than other groups of people. They are also found out to be more sensitive to salt, which increases the risk of developing hypertension.
Option B: The incidence of hypertension in Asian-Americans does not appear to be significantly higher than the general population, according to limited US data.
Option C: The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African-Americans with greater risks than Caucasians.
Option D: Hypertension prevalence rates in Hispanics may vary by gender and country of origin. Hispanic Americans overall have relatively low levels of hypertension, despite elevated levels of diabetes and obesity.
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?
A. Gastric lavage
B. Administer acetylcysteine (Mucomyst) orally
C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
D. Have the patient drink activated charcoal mixed with water
Correct Answer: A. Gastric lavage
Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.
Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of acetaminophen overdose but should be done after GI decontamination with activated charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote for acetaminophen. Acetylcysteine reduces injury by substituting for depleted glutathione in the reaction that converts the toxic metabolite of acetaminophen to its nontoxic form. When given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in preventing severe liver injury. It is administered orally or intravenously.
Option C: Intermittent IV infusion with Dextrose 5% may be considered for late-presenting or chronic ingestion.
Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be administered if the patient presents within 1 hour after ingesting a potentially toxic dose. Charcoal should not be administered immediately before or with antidotes since it can effectively adsorb it and neutralize the benefits.
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
A. Angina at rest
B. Thrombus formation
C. Dizziness
D. Falling blood pressure
Correct Answer: B. Thrombus formation
A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body.
Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular-related diseases and technique-related factors.
Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
A. Maintain fluid and electrolyte balance
B. Control nausea
C. Manage pain
D. Prevent urinary tract infection
Correct Answer: C. Manage pain
Managing pain is always a priority because it ultimately improves the quality of life. The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
Option A: IV hydration in the setting of acute renal colic is controversial. Whereas some authorities believe that IV fluids hasten the passage of the stone through the urogenital system, others express concern that additional hydrostatic pressure exacerbates the pain of renal colic.
Option B: Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating effect that is often helpful.
Option D: Overuse of the more effective antibiotic agents leaves only highly resistant bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can result in potentially life-threatening urosepsis and pyonephrosis.
- Question
What would the nurse expect to see while assessing the growth of children during their school-age years?
A. Decreasing amounts of body fat and muscle mass
B. Little change in body appearance from year to year
C. Progressive height increase of 4 inches each year
D. Yearly weight gain of about 5.5 pounds per year
Correct Answer: D. Yearly weight gain of about 5.5 pounds per year
School-age children gain about 5.5 pounds each year and increase about 2 inches in height. Between ages 2 to 10 years, a child will grow at a steady pace.
Option A: Decreasing amounts of body fat and muscle mass are common in toddlers.
Option B: A decrease in the change in body appearance occurs among young adults.
Option C: Growth spurts are common in school-age children, as are periods of slow growth.
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to:
A. Go get a blood pressure check within the next 15 minutes
B. Check blood pressure again in two (2) months
C. See the healthcare provider immediately
D. Visit the health care provider within one (1) week for a BP check
Correct Answer: A. Go get a blood pressure check within the next 15 minutes
The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke.
Options B & D: Waiting 2 months or a week for follow-up is too long.
Option C: Immediate check by the provider of care is not warranted.
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
Correct Answer: A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.
Option B: The client with antibiotic-induced diarrhea still needs continuous strict monitoring as the blood sugar levels may become unstable and dehydration is still possible.
Option C: Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters.
Option D: Cellulitis is often an underestimated complication of HIV disease, but they are responsible for an appreciable morbidity.
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
A. Should be taken in the morning
B. May decrease the client’s energy level
C. Must be stored in a dark container
D. Will decrease the client’s heart rate
Correct Answer: A. Should be taken in the morning
Option A: Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client’s sleeping pattern.
Option B: Some of the side effects of Levothyroxine include hyperactivity and an increase in heart rate.
Option C: Keep this drug in a cool, dark, and dry place.
Option D: A decrease in the heart rate is the desired effect of Levothyroxine.
A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?
A. Prepare the child for X-ray of upper airways
B. Examine the child’s throat
C. Collect a sputum specimen
D. Notify the healthcare provider of the child’s status
Correct Answer: D. Notify the healthcare provider of the child’s status. These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.
Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis.
Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort.
Option C: There are no indications for the collection of sputum specimens.
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
A. Polyphagia
B. Dehydration
C. Bedwetting
D. Weight loss
Correct Answer: C. Bedwetting
One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a school-age child is readily detected by the parents.
Option A: Polyphagia or extreme hunger is one of the most common symptoms of diabetes both among adults and children.
Option B: Dehydration is not a symptom of type 1 diabetes, but it can be one of the many complications.
Option D: Unintentional weight loss would develop gradually in a child with type 1 diabetes.
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
A. Trichomoniasis
B. Chlamydia
C. Staphylococcus
D. Streptococcus
Correct Answer: B. Chlamydia
Option B: Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. Chlamydial bacteria could travel up toward the vagina or cervix into the reproductive organs.
Option A: Trichomoniasis is a very common sexually transmitted disease, but it rarely predisposes to pelvic inflammatory disease.
Options C & D: Staphylococcus and streptococcus may cause PID but it rarely occurs.
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
B. A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?”
C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11,
D. An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.
Correct Answer: C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10.
Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. This client exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.
Option A: The client in option A might be experiencing an overdose.
Option B: The client in option B is having withdrawal syndrome.
Option D: The client in option D may experience a decrease in sensorium later on due to head trauma.
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:
A. Eating three (3) balanced meals a day
B. Adding complex carbohydrates
C. Avoiding very heavy meals
D. Limiting sodium to 7 gms per day
Correct Answer: C. Avoiding very heavy meals
Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. Too much plaque may accumulate in the arteries and block the delivery of blood and oxygen in major organs of the body.
Option A: Eating a balanced diet should be a part of the management of a client with coronary artery disease.
Option B: Complex carbohydrates decrease inflammation and help decrease the risk of plaque build-up in the arteries.
Option C: People with cardiovascular diseases should have a limit of less than 1.5 grams per day.
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working?
A. The client complains of discomfort at the IV insertion site
B. The client states “I just can’t get relief from my pain.”
C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct Answer: C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
Option A: Discomfort at the IV insertion site may indicate inflammation or infection of the site.
Option B: Morphine is a strong painkiller indicated for severe pain.
Option D: The pump is working correctly if there is only 50 ml left at noon.
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
A. Electrical energy fields
B. Spinal column manipulation
C. Mind-body balance
D. Exercise of joints
Correct Answer: B. Spinal column manipulation
The theory underlying chiropractic is that interference with the transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by the misalignment of the vertebrae. Manipulation reduces subluxation.
Option A: Too much exposure to electrical energy can become a hazard to one’s health.
Option C: Mind-body balance refers to yoga.
Option D: Low-impact aerobic exercises are easier on the joints but are not part of chiropractic medicine.
The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?
A. Decrease in the level of consciousness
B. Loss of bladder control
C. Altered sensation to stimuli
D. Emotional lability
Correct Answer: A. Decrease in the level of consciousness
A further decrease in the level of consciousness may indicate an increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal the presence of a transient ischemic attack which may warn of impending thrombotic CVA.
Option B: The patient post-stroke may have transient urinary incontinence due to inability to communicate needs, or impaired motor and postural control. Control of the urinary sphincter may also be lost or diminished.
Option C: Altered sensation to stimuli is expected for a patient post CVA. This may include sensory impairment to touch, loss of proprioception, difficulty interpreting visual, tactile, and auditory stimuli.
Option D: Depression and anxiety are common responses by a patient after a catastrophic event such as in stroke. Emotional lability (or pseudobulbar affect), refers to the involuntary and uncontrollable bursts of emotion without an emotional trigger.
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
A. Positive sweat test
B. Bulky greasy stools
C. Moist, productive cough
D. Meconium ileus
Correct Answer: C. Moist, productive cough
Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva, and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
Option A: A positive sweat test is one of the indications of cystic fibrosis.
Option B: A patient with CF experiences frequent greasy, bulky stools or difficulty with bowel movements as the thick mucus blocks the intestines.
Option D: Meconium ileus is one of the early signs of CF.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
A. Place a call to the client’s health care provider for instructions
B. Send him to the emergency room for evaluation
C. Reassure the client’s wife that the symptoms are transient
D. Instruct the client’s wife to call the doctor if his symptoms become worse
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
A. Place a call to the client’s health care provider for instructions
B. Send him to the emergency room for evaluation
C. Reassure the client’s wife that the symptoms are transient
D. Instruct the client’s wife to call the doctor if his symptoms become worse
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test?
A. Client must be NPO before the examination
B. Enema to be administered prior to the examination
C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination
D. No special orders are necessary for this examination
Correct Answer: D. No special orders are necessary for this examination
There are no special orders for this procedure, however, the client must be instructed of the general rule during radiography tests: remove any clothing, jewelry, or objects that may interfere with the test.
Option A: There is no need to keep the client on NPO before the procedure.
Option B: Enemas are not recommended for any type of radiograph test.
Option C: Furosemide (Lasix) is unnecessary for this examination.
The nurse is giving discharge teaching to a client seven (7) days post-myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?
A. “You need to regain your strength before attempting such exertion.”
B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
C. “Have a glass of wine to relax you, then you can try to have sex.”
Correct Answer: B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers.
Option A: The instruction in option A is vague and does not specifically tell the patient how to determine if the activity is already appropriate for him.
Option C: Having a glass of wine is not recommended for a client who just had a myocardial infarction.
Option D: Having an active walking program does not guarantee that the client has regained strength for strenuous activity.
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying
B. A teenager who got a singed beard while camping
C. An elderly client with complaints of frequent liquid brown colored stools
D. A middle-aged client with intermittent pain behind the right scapula
Correct Answer: B. A teenager who got a singed beard while camping
This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling.
Option A: When an infant is crying, the fontanels may look like they are bulging.
Option C: The client in Option C can wait to be seen within the first hour.
Option D: The client in Option D does not have a life-threatening condition but will still require immediate pain relief.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
A. “I want to protect my child from any falls.”
B. “I will set limits on exploring the house.”
C. “I understand the need to use those new skills.”
D. “I intend to keep control over our child.”
Correct Answer: C. “I understand the need to use those new skills.”
Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment and develop autonomy.
Option A: The statement in Option A is correct but pertains to the risks associated with a toddler.
Option B: Setting limits on a toddler may cause frustration instead of independence.
Option D: Controlling the child may be harmful to her development as toddlers should be developing their autonomy at this stage.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
A. Verify correct placement of the tube
B. Check that the feeding solution matches the dietary order
C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
D. Ensure that feeding solution is at room temperature
Correct Answer: A. Verify correct placement of the tube
Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach.
Option B: It is also important to check that the feeding solution matches the dietary order to ensure that the client gets proper nutrition.
Option C: Aspirating the gastric contents is one of the methods used to determine the last feeding amount in the stomach, but is not the most important action the nurse should do.
Option D: Keep it at room temperature so it would not upset the stomach.
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
A. Narrowed QRS complex
B. Shortened “PR” interval
C. Tall peaked “T” waves
D. Prominent “U” waves
Correct Answer: C. Tall peaked “T” waves
A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing the medication.
Option A: Narrow QRS complex indicates fast cardiac rhythms (generally more than 100 beats/min) with a QRS duration of 100 ms or less.
Option B: A short PR interval (<120 ms) is seen with preexcitation syndromes and AV nodal (junctional) rhythm.
Option D: Prominent U waves are characteristic of hypokalemia.
A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
A. All striated muscles
B. The cerebellum
C. The kidneys
D. The leg bones
Rhabdomyosarcoma is the most common children’s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. Symptoms of rhabdomyosarcoma include if the cancer is in the head or neck area: sudden bulging or swelling of the eyes, conjunctival chemosis, and headache. It can also affect the urinary or reproductive system. Its common site of metastasis is the lung.
Option B: The cerebellum is not affected in rhabdomyosarcoma.
Option C: The kidneys are not directly affected by the disease.
Option D: Bones are not directly affected by the disease
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to:
A. Achieve harmony
B. Maintain a balance of energy
C. Respect life
D. Restore yin and yang
Correct Answer: D. Restore yin and yang
For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang. Traditional Chinese medicine is a medical system that began being developed in China about 5000 years ago, which makes it the oldest continuous medical system on the planet.
Option A: Living in harmony with one’s natural environment with the aim of keeping all aspects of a person-mind, body, and spirit- in a state of harmony and balance so that disease never has a chance to develop.
Option B: This balance and a healthy lifestyle are the focus of Chinese medicine which empowers the individual to participate in his own health.
Option C: In Chinese medicine, the body, and indeed a human being, is not seen as a machine, living in isolation from the world around it. Human beings are seen as part of the whole of things, which includes our environments, nature, and the universe itself.
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to:
A. Increase fluids that are high in protein
B. Restrict fluids
C. Force fluids and reassess blood pressure
D. Limit fluids to non-caffeine beverages
Correct Answer: C. Force fluids and reassess blood pressure
Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.
Option A: Fluids may not be necessarily protein-rich.
Option B: Restricting fluids could aggravate the client’s dizziness.
Option D: There is no need to restrict the fluid intake of the client.
