Nokea
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
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Which of the ff is a sign or symptom characteristic of the later stages of TB?
- A. Fatigue
- B. Anorexia
- C. Hemoptysis
- D. Weight loss
Correct Answer: C
Rationale: Hemoptysis, which refers to coughing up blood, is a sign characteristic of the later stages of tuberculosis (TB). This symptom occurs when there is significant damage to the lungs due to the progression of the disease. Hemoptysis in TB can indicate advanced disease and the presence of cavities in the lungs where blood vessels may become eroded. It is a serious symptom that often requires immediate medical attention. While fatigue, anorexia, and weight loss are common symptoms of TB, hemoptysis specifically points towards the later stages of the disease and severe lung involvement.
Which is characteristic of newborns whose mothers smoked during pregnancy?
- A. Large for gestational age
- B. Preterm, but size appropriate for gestational age
- C. Growth retardation in weight only
- D. Growth retardation in weight, length, and head circumference
Correct Answer: D
Rationale: Newborns whose mothers smoked during pregnancy often display growth retardation in weight, length, and head circumference. Maternal smoking is associated with intrauterine growth restriction, leading to reduced size parameters at birth. This can result in newborns being smaller in weight, length, and head circumference compared to newborns of mothers who did not smoke during pregnancy. Smoking during pregnancy can have negative effects on the developing fetus, contributing to various health risks and growth abnormalities in newborns.
The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.
The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection?
- A. Increased fluid intake
- B. Short urethra in young girls
- C. Prostatic secretions in males
- D. Frequent emptying of the bladder
Correct Answer: B
Rationale: One of the factors that predisposes the urinary tract to infection is a short urethra in young girls. The shorter urethra compared to boys makes it easier for bacteria to travel up the urinary tract and cause infections. This anatomical difference in young girls increases their susceptibility to urinary tract infections compared to boys. In boys, the longer length of the urethra provides a natural barrier for bacteria to enter the bladder, reducing the risk of infection.
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.