Nursing Elites

1. The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

• A. Muscle tetany
• B. Syncope
• C. Numbness
• D. Anxiety

Correct answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

2. A patient has been diagnosed with Guillain-Barre Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre Syndrome with the patient?

• A. Guillain-Barre Syndrome improves in almost all cases within 5 years.
• B. Guillain-Barre Syndrome causes limited sensation in the abdominal region.
• C. Guillain-Barre Syndrome causes muscle weakness in the legs.
• D. Guillain-Barre Syndrome affects breathing in severe cases.

Correct answer: C

Rationale: The correct statement is that Guillain-Barre Syndrome causes muscle weakness in the legs. This muscle weakness typically starts in the legs and can progress to the upper body. Choice A is incorrect as while most cases do improve, the recovery time can vary. Choice B is incorrect as Guillain-Barre Syndrome primarily affects muscle weakness rather than sensation. Choice D is incorrect as severe cases of Guillain-Barre Syndrome can lead to respiratory muscle weakness, impacting breathing.

3. Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. primary health care prevention

Correct answer: B

Rationale: The correct answer is B: secondary prevention. This type of prevention focuses on reducing the impact of a disease by early detection and treatment. In the case of gonorrhea, teaching the client how to prevent reinfection and further spread falls under secondary prevention because it aims to reduce the prevalence and morbidity of the disease. Choice A (primary prevention) involves measures to prevent the disease from occurring in the first place, such as vaccination. Choice C (tertiary prevention) focuses on managing the long-term consequences of a disease to prevent complications. Choice D (primary health care prevention) is not a recognized term in prevention strategies.

4. Which of the following medications is not classified as a neuromuscular blocker?

• A. Anectine
• B. Pavulon
• C. Pitressin
• D. Mivacron

Correct answer: C

Rationale: The correct answer is Pitressin. Pitressin is a hormone replacement medication and is not classified as a neuromuscular blocker. Choices A, B, and D (Anectine, Pavulon, Mivacron) are neuromuscular blockers used during anesthesia to induce muscle relaxation for various procedures. Anectine is also known as succinylcholine, Pavulon is rocuronium, and Mivacron is mivacurium. These medications act on the neuromuscular junction to block the transmission of nerve impulses, leading to muscle relaxation.

5. Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa's complaints with which of the following statements?

• A. "The physician will probably want to admit you for observation."?
• B. "The physician will probably order bedrest at home."?
• C. "These are really dangerous signs."?
• D. "The physician will probably prescribe some medicine for you."?

Correct answer: B

Rationale: Pregnancy-induced hypertension (PIH) is a hypertensive disorder of pregnancy that can present after 20 weeks gestation. It is characterized by symptoms like edema, hypertension, and proteinuria, which can progress to conditions like pre-eclampsia and eclampsia. The best approach for a client with advanced PIH is rest, and home provides the most suitable environment for it. Hospitalization is not typically necessary for PIH unless there are severe complications. Medication alone is not the primary intervention for PIH; management often involves monitoring, rest, and close medical supervision. Therefore, advising bedrest at home is the most appropriate response to help manage PIH symptoms and prevent further complications, such as pre-eclampsia or eclampsia. The other options, like hospitalization for observation, emphasizing the danger of the signs without providing guidance, or assuming medication as the primary solution, are not in line with the standard management approach for PIH.

Similar Questions