Nokea
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
- A. "The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!"
- B. "His stroke has made him less inhibited. We'll see if we can find a male assistant to help him."
- C. "We have to take care of all patients equally, even the dirty old men."
- D. "He didn't mean anything by it, just ignore it."
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
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Which of the ff. is a normal hemoglobin value?
- A. 38% to 48%
- B. 48 to 54 mg%
- C. 12 to 18 g/100mL
- D. 27 to 36 g/dL
Correct Answer: C
Rationale: The normal hemoglobin values are typically expressed in grams per deciliter (g/dL) or grams per 100 milliliters (g/100mL) of blood. The range of 12 to 18 g/100mL is considered the normal range for hemoglobin levels in adults. Hemoglobin values outside of this range may indicate various health conditions such as anemia or polycythemia. Option A (38% to 48%) is a range for hematocrit, not hemoglobin. Option B (48 to 54 mg%) and Option D (27 to 36 g/dL) are not within the standard normal range for hemoglobin levels.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?
- A. Inappropriate, because of child's age
- B. A way to establish rapport
- C. Too distracting, when cooperation is important
- D. Acceptable, if there is adequate time
Correct Answer: B
Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.
A very popular means of early detection of breast cancer is:
- A. X-ray
- B. Both A and B
- C. Surgical
- D. Breast self examination
Correct Answer: D
Rationale: Breast self-examination (BSE) is a very popular means of early detection of breast cancer as it involves women being aware of how their breasts look and feel to detect any changes such as lumps, swelling, or other abnormalities. By performing regular self-examinations, women can identify any potential issues early on and seek medical advice promptly. While mammograms (X-ray) and clinical breast exams by healthcare providers are also important screening methods for detecting breast cancer, BSE is particularly valuable as women can perform it on a regular basis at home, thus increasing the chances of identifying any concerning changes promptly. It is recommended that women perform BSE monthly to become familiar with their breast tissue and notice any changes over time.
which of the following is true concerning rheumatic fever?
- A. it is usually associated with glomerulonephritis
- B. symptoms disappear shortly after the fever abate and the temperature returns to normal
- C. the child should resume normal activities as soon as she feels well
- D. it usually follows a streptococcal infection
Correct Answer: D
Rationale: Rheumatic fever is an inflammatory disease that can develop as a complication of inadequately treated streptococcal infections, especially streptococcal throat infections caused by group A streptococcus bacteria. The bacteria trigger an abnormal immune response in susceptible individuals, leading to the development of rheumatic fever. The other choices are not accurate. Glomerulonephritis is a separate condition associated with certain types of streptococcal infections but not with rheumatic fever. Symptoms of rheumatic fever can persist even after the fever has subsided, and it is important for children with rheumatic fever to follow proper treatment and rest guidelines as advised by healthcare providers. It is crucial for individuals with rheumatic fever to avoid activities that could strain the heart until the condition has been properly managed.
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.