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A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
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The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations should the nurse expect to see?
- A. Hypoglycemic, large for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, small for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Infants born to mothers with diabetes, especially uncontrolled diabetes, are at risk for hypoglycemia due to exposure to high glucose levels in utero. The infant's pancreas may have been producing high levels of insulin in response to the mother's high blood glucose levels, leading to hypoglycemia after birth. Additionally, these infants are typically smaller for gestational age (SGA) due to the effects of high blood sugar levels on fetal growth. Therefore, the nurse should expect the newborn of a mother with diabetes to exhibit signs of hypoglycemia and be small for gestational age.
The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
- A. achieves a weight of at least 3 pounds.
- B. indicates an interest in breastfeeding.
- C. does not require supplemental oxygen.
- D. has adequate sucking and swallowing reflexes.
Correct Answer: D
Rationale: Breastfeeding can be initiated when the newborn has adequate sucking and swallowing reflexes, which usually develop around 34 to 36 weeks gestational age. It is important for the newborn to have the ability to latch onto the breast and suck effectively in order to receive adequate nutrition and establish a good breastfeeding relationship with the mother. Indicating an interest in breastfeeding is important as well, but having the reflexes necessary for successful breastfeeding is a key factor in determining readiness to begin breastfeeding.
Assume you are going to estimate the prevalence of amoebic dysentery in a small country which harbors a total number of population of 530,000; you find that 57,000 of the population are infected by the disease. The prevalence of this disease is closest to
- A. 5.33%
- B. 7.45%
- C. 10.75%
- D. 20.22%
Correct Answer: C
Rationale: Prevalence = (Number of infected / Total population) * 100 = (57,000 / 530,000) * 100 ≈ 10.75%.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.
Which occurs in septic shock?
- A. Hypothermia
- B. Increased cardiac output
- C. Vasoconstriction
- D. Angioneurotic edema
Correct Answer: C
Rationale: In septic shock, vasoconstriction is a common phenomenon. This occurs as part of the body's response to the infection, where blood vessels constrict in an attempt to maintain blood pressure and perfusion to vital organs. The vasoconstriction leads to increased systemic vascular resistance and contributes to the hypotension seen in septic shock. The body's natural response to infection also involves a release of inflammatory mediators, which can cause vasodilation in some areas while concurrent vasoconstriction occurs in others, resulting in uneven blood flow distribution and contributing to organ dysfunction. Therefore, vasoconstriction is a key factor in the pathophysiology of septic shock.