Nokea
A 9-mo-old infant is recently diagnosed with bilateral retinoblastoma; examination under anesthesia reveals bilateral multifocal involvement of the retina. An important next step in the management is
- A. radiotherapy of both eyes
- B. retinal examination of 1st degree relatives
- C. orbital ultrasonography
- D. bilateral enucleation
Correct Answer: B
Rationale: Retinal examination of first-degree relatives is crucial to identify hereditary forms of retinoblastoma.
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Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with larged-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting use of eye drops for comfort
- D. Suggesting use of glasses or contact lenses CARING FOR CLIENTS WITH EYE DISORDERS
Correct Answer: D
Rationale: As people age, changes in the lens of the eye can lead to difficulty focusing on close objects, a condition known as presbyopia. Suggesting the use of glasses or contact lenses can help older clients compensate for these age-related lens changes and improve their visual acuity for tasks such as reading or other close-up activities. Glasses or contact lenses prescribed by an eye care professional can provide the appropriate magnification needed to address the visual changes associated with aging, promoting comfort and maintaining independence for older clients.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: Maintaining strict aseptic technique during thoracentesis is the most crucial nursing intervention. Thoracentesis is a procedure where a needle is inserted into the pleural space to obtain a sample of fluid for diagnostic purposes or to drain excess fluid for therapeutic relief. It is essential to prevent the introduction of pathogens or contaminants into the pleural space, as this can lead to serious complications such as infection. By following strict aseptic technique, the risk of complications can be minimized, ensuring the safety and well-being of the patient undergoing the procedure.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: Keeping the extremities at a neutral position for a client with a neurologic disorder can help reduce hemostasis and decrease the potential for thrombophlebitis. This positioning helps maintain proper blood flow and prevents excessive pressure on the veins, which can lead to blood clots. Removing and reapplying elastic stockings, changing the client's position, and using a flotation mattress may have their own benefits, but in this case, keeping the extremities at a neutral position is the most direct and effective intervention to address the issue of hemostasis and thrombophlebitis for a client with a neurologic disorder.
A 2 years old girl presents with blue discoloration of nails and lips. On examination she is cyanosed and clubbed, heart auscultation reveals a short systolic murmur at left upper sternal border. The most likely diagnosis is?
- A. VSD
- B. Tetralogy of Fallot
- C. Tricuspid atresia
- D. Trunchus arteriosus
Correct Answer: B
Rationale: Tetralogy of Fallot typically causes cyanosis, clubbing, and a systolic murmur due to right-to-left shunting.
When communicating with other professionals, what is important for the nurse to do?
- A. Ask others what they want to know.
- B. Share everything known about the family.
- C. Restrict communication to clinically relevant information.
- D. Recognize that confidentiality is not possible.
Correct Answer: C
Rationale: When communicating with other professionals, it is important for the nurse to restrict communication to clinically relevant information. This ensures that only necessary and pertinent information is shared, maintaining patient confidentiality and preventing the unnecessary dissemination of sensitive details. By focusing on clinically relevant information, healthcare professionals can collaborate effectively and make well-informed decisions about patient care without compromising confidentiality or violating ethical guidelines.