Nokea
A 16-year-old discusses his recent diagnosis of lupus with the nurse. Which statement best describes adolescent thinking regarding the future?
- A. Adolescents are preoccupied with the present.
- B. Adolescents are beginning to think abstractly and consider future possibilities.
- C. Adolescents think only in concrete terms.
- D. Adolescents are overly concerned with past events.
Correct Answer: B
Rationale: During adolescence, abstract thinking develops, allowing teens to envision future possibilities.
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Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: Tension headaches are commonly described as a sensation of pressure, tightness, or steady constriction around the head. This discomfort is usually felt on both sides of the head, rather than being localized to one specific area. Unlike migraines which may have a pulsating or throbbing quality, tension headaches are characterized by a continuous dull ache. Sensitivity to light (photophobia) and vague headaches are more commonly associated with migraines, not tension headaches. Temporary unilateral paralysis and peri orbital pain are not typical symptoms of tension headaches.
A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?
- A. Heart rate, respiratory rate, and bloodpressure
- B. Recent exposure to communicable diseases
- C. Number of immunizations received
- D. Height and weight
Correct Answer: A
Rationale: In this situation, the priority data the nurse should obtain first is the vital signs including heart rate, respiratory rate, and blood pressure of the child. This information will help assess the child's current physiological status and potential effects of ingesting the aspirin. Aspirin overdose in children can lead to serious complications such as metabolic acidosis, respiratory distress, and cardiovascular instability. Monitoring the vital signs will provide crucial information to guide appropriate interventions and determine the severity of the child's condition. Height and weight (option D) are important for routine assessments but not the priority in this urgent situation. Recent exposure to communicable diseases (option B) and number of immunizations received (option C) are not relevant to the immediate management of the child's aspirin ingestion.
Which of the ff nursing interventions ensure that a client with Hodgkin's disease remains free of infection? Choose all that apply
- A. Apply ice to the skin for brief periods
- B. Provide cool sponge baths
- C. Practice conscientious hand washing
- D. Use cotton gloves Restrict visitors or personnel with infections from contact with the client
Correct Answer: C
Rationale: #NAME?
Which of the ff. descriptions by the nurse would best explain glaucoma to a patient?
- A. "There is an increase in the amount of vitreous humor."
- B. "There is an increase in the intraocular pressure."
- C. "There is a decrease in the amount of aqueous humor."
- D. "There is a decrease in the intraocular pressure."
Correct Answer: B
Rationale: Glaucoma is a group of eye conditions that damage the optic nerve, usually due to high intraocular pressure (IOP). In glaucoma, there is an imbalance between the production and drainage of aqueous humor in the eye, leading to increased pressure inside the eye. This elevated pressure can cause damage to the optic nerve, which is essential for vision, resulting in vision loss. Therefore, the best description by the nurse to explain glaucoma to a patient would be that there is an increase in intraocular pressure (Choice B).
During the routine exam of an infant the parents state a 5th degree family history of adenomatous polyposis. The statement that should be included during the discussion is the infant is at increased risk of colonic adenocarcinoma
- A. the infant is at increased risk of acute lymphocytic leukemia
- B. the infant is at increased risk of intestinal Burkitt lymphoma
- C. the infant is at increased risk of hepatoblastoma
- D. the infant is at increased risk of germ cell tumor
Correct Answer: C
Rationale: Familial adenomatous polyposis significantly increases the risk of developing colorectal cancer.