Nokea
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.
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You are evaluating a 6-year-old child with ALL on interim maintenance phase who has frequent mucositis and myelosuppression that needs frequent discontinuation of his treatment. Of the following, the MOST valuable test for this child is
- A. complete blood count
- B. pharmacogenetic testing of the thiopurine S-methyltransferase (TPMT) gene
- C. renal function test
- D. bone marrow study
Correct Answer: B
Rationale: TPMT gene testing helps determine the child's ability to metabolize thiopurine drugs, which may explain the adverse effects.
The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia. Which intervention is the most appropriate during the acute phase?
- A. Allow newborn to sleep with pacifier to decrease stimuli.
- B. Keep newborn awake to monitor central nervous system changes.
- C. Encourage parents to hold and feed newborn to facilitate attachment during illness.
- D. Awaken newborn periodically to assess level of consciousness.
Correct Answer: D
Rationale: During the acute phase of treatment with IV calcium gluconate for hypocalcemia in a newborn, it is essential to closely monitor the newborn's level of consciousness. Hypocalcemia can lead to central nervous system changes, such as irritability, jitteriness, and seizures. By awakening the newborn periodically to assess their level of consciousness, the nurse can promptly identify any signs of worsening central nervous system involvement and take appropriate action. This intervention ensures timely detection of any neurological complications and allows for timely intervention to prevent serious consequences. The other options do not address the importance of monitoring for central nervous system changes during the acute phase of treatment for hypocalcemia.
minutes of birth may be as high as:
- A. 50
- B. 60
- C. 80
- D. 100
Correct Answer: D
Rationale: The number of minutes in an hour is 60. Therefore, the maximum number of minutes at birth can only be 60 minutes in an hour. Since the options provided are all above 60, the highest plausible option is 100 minutes, making option D the correct answer.
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: A
Rationale: Patients with multiple myeloma are at an increased risk of bleeding due to low levels of platelets, which play a key role in blood clotting. Uncontrolled bleeding can occur in multiple myeloma patients, leading to serious complications such as hemorrhage and anemia. Therefore, the nurse should monitor for signs of bleeding, such as easy bruising, petechiae, or prolonged bleeding from minor cuts or procedures, and take appropriate interventions to manage and prevent further bleeding episodes in the patient with multiple myeloma. Monitoring for and addressing uncontrolled bleeding is crucial in ensuring the safety and well-being of the patient.
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.