Nokea
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.'s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct option is B - Use a soft toothbrush and electric razor. When a patient is diagnosed with myelocytic leukemia and has bone marrow depression as indicated by laboratory results, the platelet count is usually low which can lead to increased risk of bleeding. Therefore, it is important for the patient to use a soft toothbrush and electric razor to minimize the risk of injury and bleeding. Hard toothbrushes and sharp razors can cause damage to the gums and skin, leading to bleeding complications. It is essential to take precautions to prevent injury and promote safety for the patient undergoing chemotherapy with bone marrow depression.
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An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client's fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.
A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the parents on which method of care for the umbilical cord? (Select all that apply.)
- A. Covering the cord with the diaper
- B. Cleansing the cord with water daily
- C. Keeping the cord area free of urine and stool
- D. Monitoring for signs of infection
Correct Answer: B
Rationale: Cleansing the cord with water daily - It is important to keep the umbilical cord clean to prevent infection. Cleaning it with water helps remove any debris or bacteria that may have accumulated.
The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Congenital heart disease
Correct Answer: B
Rationale: One of the most frequent causes of hypovolemic shock in children is blood loss. Children are at risk for blood loss due to trauma, surgical procedures, gastrointestinal bleeding, or other conditions that result in significant blood volume reduction. Blood loss leads to a decrease in circulating blood volume, which in turn reduces tissue perfusion and oxygen delivery to vital organs. This results in hypovolemic shock, where the heart is unable to pump sufficient blood to meet the body's needs, leading to organ dysfunction and potentially life-threatening complications. Therefore, recognizing and addressing blood loss promptly is essential in managing hypovolemic shock in children.
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
- A. Providing tepid sponge bath
- B. Applying ice packs
- C. Administering prescribed antipyretics
- D. Keeping the room temperature warm
Correct Answer: A
Rationale: A. Providing tepid sponge bath: This measure helps to gradually lower the body temperature by promoting heat loss through evaporation. It is a safe and effective way to cool down someone with a fever.
Which is most descriptive of clinical reasoning?
- A. A simple developmental process
- B. Purposeful and goal-directed
- C. Based on deliberate and irrational thought
- D. Assists individuals in guessing what is most appropriate
Correct Answer: B
Rationale: Clinical reasoning is a complex cognitive process used by healthcare providers to make sound clinical decisions about patient care. It involves the gathering and analyzing of information, as well as the formulation and evaluation of potential treatment options. Clinical reasoning is purposeful in that it is driven by the goal of providing the best possible care for the patient. Healthcare providers use their knowledge, skills, and experience to systematically work through patient problems, identify possible solutions, and make informed decisions. The process is goal-directed, aiming to achieve positive health outcomes for the patient based on the best available evidence and clinical expertise.