Nokea
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.
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A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?
- A. "The bladder irrigation is needed to stop the bleeding in the bladder."
- B. "Antibiotics are being administered into the bladder to prevent infection."
- C. "The irrigation is needed to keep the catheter from becoming occluded by blood clots."
- D. "Normal production of urine is maintained with the irrigations until healing can occur."
Correct Answer: C
Rationale: The best explanation for the patient is option C, which states, "The irrigation is needed to keep the catheter from becoming occluded by blood clots." After a transurethral resection of the prostate (TURP), it is common for the patient to have some bleeding in the bladder. Bladder irrigation is done to prevent blood clots from forming and blocking the catheter. Keeping the catheter patent is important to ensure proper drainage of urine and prevent complications such as urinary retention. While the other options are related to potential reasons for bladder irrigation, option C directly addresses the immediate concern of preventing catheter occlusion by blood clots post-TURP surgery.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?
- A. At 1 to 2 years of age
- B. At I week to 1 year of age, peaking at 2 to 4 months
- C. At 6 months to 1 year of age, peaking at 10 months
- D. At 6 to 8 weeks of age
Correct Answer: B
Rationale: Sudden infant death syndrome (SIDS) is most likely to occur between the ages of 1 week to 1 year, with the highest risk period being between 2 to 4 months of age. While SIDS can occur up to the age of 1 year, the peak incidence is during the first 6 months of life. It is important to follow safe sleep practices, such as placing infants on their backs to sleep, to reduce the risk of SIDS during this vulnerable period.
A parent asks the nurse to define Talipes Varus. The nurse tells the parent that it is which of the following?
- A. An inversion or bending inward of the foot.
- B. An eversion or bending outward of the foot.
- C. A high arch of the foot.
- D. A low arch (flatfoot) of the foot.
Correct Answer: A
Rationale: Talipes Varus is a congenital deformity that involves the inward bending or inversion of the foot. The word "varus" specifically refers to the inward deviation of a body part, such as the foot in this case. This condition is also known as clubfoot, where the foot is twisted internally and downward. Treatment typically involves gentle manipulation and stretching of the foot, followed by casting or bracing to gradually correct the position of the foot.
The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family?
- A. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
- B. Instruct the parents that the child will probably need to have daily enemas.
- C. Suggest the use of stimulant cathartics weekly.
- D. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
Correct Answer: D
Rationale: The most appropriate response for the nurse to include in the discussion with the family of a child with a history of encopresis is to reassure them that most problems are resolved successfully, with some relapses during periods of stress. Encopresis is a common disorder in childhood, characterized by the repeated passage of feces in inappropriate places. It is often related to chronic constipation and fecal impaction. Treatment for encopresis includes addressing the underlying constipation through interventions like dietary changes, behavioral therapies, and possibly medications. It is important for the nurse to educate the family that although it may take time and effort, most children improve with treatment. Reassuring the family that relapses during periods of stress are to be expected can help to alleviate some of their anxiety and encourage them to continue with the treatment plan.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.