Nokea
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
- A. 8 mm Hg
- B. 25 mm Hg
- C. 11 mm Hg
- D. 28 mm Hg
Correct Answer: C
Rationale: Normal intraocular pressure (IOP) typically ranges between 10 and 21 mm Hg. For this reason, the tonometer measurements of 11 mm Hg and 20 mm Hg fall within the normal range. Therefore, clients with these IOP values (Option C and E) have normal intraocular pressure. The other options (A, B, and D) are outside the normal range for IOP and are therefore considered elevated.
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How does the nurse assess a child's capillary refill time?
- A. Inspecting the chest
- B. Auscultating the heart
- C. Palpating the apical pulse
- D. Palpating the skin to produce a slight blanching
Correct Answer: D
Rationale: Capillary refill time is a clinical assessment used to evaluate peripheral perfusion. To perform this assessment on a child, the nurse would gently press on the child's nail bed or skin, causing the area to momentarily blanch (turn white) as blood is temporarily forced out of the capillaries. Once pressure is released, the nurse observes and times how quickly the color returns to normal. A normal capillary refill time in a child is less than 2 seconds. This method helps the nurse determine if the child's peripheral circulation is adequate. Inspecting the chest (choice A), auscultating the heart (choice B), and palpating the apical pulse (choice C) are not appropriate methods for assessing capillary refill time.
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: Hyponatremia is a condition characterized by low levels of sodium in the blood. Encouraging the intake of low-sodium liquids, such as coffee or tea, can further dilute the sodium levels in the body and worsen the condition. Instead, it is important to restrict fluid intake and focus on providing appropriate electrolyte replacement. Monitoring the patient's neurological status is crucial as severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma. Assessing for symptoms like nausea and malaise helps in understanding the patient's condition. Restricting tap water intake is also necessary to help manage hyponatremia by preventing further dilution of sodium levels.
A baby is born precipitously in the ER. The nurses initial action should be to:
- A. Establish an airway for the baby
- B. Ascertain the condition of the fundus
- C. Quickly tie and cut the umbilical cord
- D. Move mother and baby to the birthing unit
Correct Answer: A
Rationale: The initial action that the nurses should take after a baby is born precipitously in the ER is to establish an airway for the baby. This is crucial for ensuring the baby's ability to breathe properly and for their overall well-being. Clearing the airway helps prevent complications such as asphyxia and ensures that the baby is receiving adequate oxygen. Once the airway has been established and the baby's breathing is stable, then other assessments and actions can be taken.
Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: When it comes to snake bites, one should not exercise the bitten extremity as it can increase the spread of venom in the body. Moving the affected limb can potentially lead to the venom spreading more quickly through the lymphatic system and into the bloodstream. Therefore, it is essential to keep the victim as calm and still as possible to minimize the effects of the venom. Proper first aid for snake bites includes keeping the victim calm, immobilizing the bitten limb, and seeking immediate medical attention.
A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
- A. Bacterial infection
- B. High-fat diet
- C. Heredity
- D. Autoimmune reaction
Correct Answer: D
Rationale: Guillain-Barre Syndrome (GBS) is an autoimmune disorder where the body's immune system mistakenly attacks the peripheral nerves. This leads to inflammation that damages the nerves and interrupts their ability to send signals to the brain. In the case of the 32-year-old male patient with weak legs, the autoimmune reaction is most likely responsible for causing muscle weakness and difficulty walking. GBS typically presents with ascending muscle weakness starting in the legs and progressing upwards. It is essential to recognize this condition promptly as it can lead to severe complications such as respiratory failure. Treatment often involves supportive care and interventions to manage the autoimmune response.