Nokea
Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
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Where in the health history should the nurse describe all details related to the chief complaint?
- A. Past history
- B. Chief complaint
- C. Present illness
- D. Review of systems
Correct Answer: C
Rationale: The nurse should describe all details related to the chief complaint under the "Present illness" section of the health history. This section focuses specifically on the patient's current health problem, including the onset, duration, severity, aggravating or alleviating factors, and associated symptoms. It provides a comprehensive understanding of the chief complaint and helps guide further assessment and treatment interventions. The "Chief complaint" section typically contains a concise statement from the patient regarding the main reason for seeking healthcare.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
- A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue.
- B. The nurse should help the mother restrain the child to prevent him from injuring himself.
- C. The nurse should call the operator to page for seizure assistance.
- D. The nurse should clear the area and position the client safely.
Correct Answer: D
Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.
Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:
- A. avoidance of eye contact.
- B. an associated malabsorption defect.
- C. weight that falls below the 15th percentile.
- D. normal achievement of developmental landmarks.
Correct Answer: C
Rationale: Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories may include weight that falls below the 15th percentile on growth charts. Weight falling below the 15th percentile may indicate poor nutrition intake leading to inadequate growth and development. Other signs such as avoidance of eye contact, an associated malabsorption defect, and normal achievement of developmental landmarks may not be specific indicators of failure to thrive due to behavioral problems with inadequate calorie intake.
Which is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats?
- A. Social isolation
- B. Level of stress
- C. Degree of depression
- D. Desire to punish others
Correct Answer: D
Rationale: The most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats is the desire to punish others. Individuals who commit suicide often exhibit behaviors or thought patterns indicating a desire to cause harm or guilt to others. This desire to punish others may drive them to take their own lives as a way to make others feel responsible or suffer the consequences of their actions. On the other hand, individuals who make suicidal attempts or threats may not have the same level of intent to harm others through their actions, and their motivations may stem from different underlying issues such as social isolation, stress, or depression. Therefore, the desire to punish others is a crucial factor that sets those who commit suicide apart from those who make attempts or threats.
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: Older adults should be closely monitored when receiving IV therapy because their defense mechanisms are less efficient (A) as they age, making them more susceptible to infections and complications from invasive procedures like IV therapy. Additionally, older adults are prone to reduced renal efficiency (C), which can affect their ability to excrete excess fluids and electrolytes properly. Monitoring for signs of fluid overload and renal impairment is crucial in this population to prevent adverse outcomes related to IV therapy.