Nokea
The nurse understands that for the parathyroid hormone to exert its effect, what must be present?
- A. Decreased phosphate level
- B. Functioning thyroid gland
- C. Adequate vitamin D level
- D. Increased calcium level
Correct Answer: D
Rationale: Parathyroid hormone (PTH) is released by the parathyroid glands in response to low calcium levels in the blood. Its primary function is to regulate calcium and phosphorus levels in the body. When calcium levels in the blood are low, PTH is released, leading to increased calcium levels by stimulating the release of calcium from the bones, increasing calcium absorption in the intestines, and promoting calcium reabsorption in the kidneys. Therefore, for PTH to exert its effect, increased calcium levels must be present.
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You are examining an infant with multiple cutaneous hemangiomas; you suspect involvement of internal organs. The MOST common site of visceral involvement by hemangiomas is
- A. brain
- B. heart
- C. lung
- D. liver
Correct Answer: D
Rationale: Liver is the most common site of visceral involvement by hemangiomas.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The most appropriate position for a patient with right-sided paralysis following a stroke is Option B - On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James' neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: Placing 2 fingers between the tracheostomy tie and the neck is a reliable method to ensure that the tie is not too tight. This technique allows for proper circulation around the neck area and helps prevent skin irritation or pressure ulcers from developing. It strikes a balance between securing the tracheostomy in place and maintaining the patient's comfort and safety. Checking for appropriate tightness by using the finger method is a standard practice in tracheostomy care to prevent complications related to excessive pressure or constriction.
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
- A. Humidifying the environment
- B. Avoiding a skin lubricant
- C. Bathing with a bar soap that contains lye
- D. Wearing cotton gloves, esp during sleep
Correct Answer: D
Rationale: Wearing cotton gloves, especially during sleep, would help protect the skin from further irritation caused by scratching during the night. Cotton is a breathable fabric that is gentle on the skin and can help prevent further damage or itching. It also helps in maintaining the skin intact by creating a barrier between the skin and external irritants, thus reducing the chances of exacerbating the allergic reaction.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)
- A. Thirst and diminished urinary output
- B. Irritability and apprehension
- C. Cool extremities and decreased skin turgor
- D. Confusion and somnolence
Correct Answer: C
Rationale: Cool extremities and decreased skin turgor (C) are indications of poor perfusion as shock progresses. The body is shunting blood away from the peripheries to maintain perfusion to vital organs.