Nokea
24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?
- A. Pink, moist, and slightly protruding from the abdomen
- B. Gray, moist, and slightly protruding from the abdomen
- C. Pink, dry, and slightly protruding from the abdomen
- D. Red, moist, and slightly protruding from the abdomen
Correct Answer: A
Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.
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What is the term for mobilizing people to become aware of their own problems and to take action to solve them?
- A. Community Organizing
- B. Family Nursing Care Plan
- C. Nursing Intervention
- D. Nursing Process
Correct Answer: A
Rationale: The correct answer is Community Organizing. This involves engaging and mobilizing individuals in a community or group to take action for the mutual benefit or to solve common problems. The options 'Family Nursing Care Plan', 'Nursing Intervention', and 'Nursing Process' are incorrect as these terms refer to specific nursing practices and methods, not the broader action of mobilizing and engaging a community to solve its own problems. Moreover, the provided rationale does not match the original question and correct answer. It instead describes the proactive and preventative nature of nursing care, which is unrelated to the concept of community organizing.
All of the following are instructions for proper foot care to be given to a client with peripheral vascular disease caused by diabetes. Which one is not?
- A. Trim nails using a nail clipper
- B. Apply cornstarch to the foot
- C. Always check the temperature of the water before bathing
- D. Use canvas shoes
Correct Answer: A
Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.
Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?
- A. At 2 years old, you may
- B. As early as 1 year old
- C. When she's 3 years old
- D. When she's 6 years old
Correct Answer: D
Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.
Which food item interferes with the effectiveness of warfarin?
- A. Cauliflower
- B. Zucchini
- C. Green beans
- D. Broccoli
Correct Answer: D
Rationale: Broccoli is high in vitamin K, which can affect the effectiveness of warfarin. Warfarin is an anticoagulant medication that functions by reducing the activity of vitamin K in the body. When one consumes broccoli, which is rich in vitamin K, it could counteract the anticoagulant effect of warfarin, thereby interfering with its effectiveness. On the other hand, cauliflower, zucchini, and green beans do not have significant levels of vitamin K and hence, are not known to impact the effectiveness of warfarin.
Which food would benefit an anemic patient by increasing their intake?
- A. Beef
- B. Apples
- C. White bread
- D. Fish
Correct Answer: A
Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.