Nokea
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
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What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: In a right-handed individual experiencing a stroke that affects the left side of the cortex, the deficits are typically seen on the opposite side of the body due to the way the brain is wired. This phenomenon is known as contralateral organization. In this scenario, the left side of the brain controls the right side of the body.
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects:
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
- A. Wrap the neonate warmly and place her in an open crib
- B. Administer an oral glucose feeding of 10% dextrose in water
- C. Increase the temperature setting on the radiant warmer
- D. Obtain an order for IV fluid administration
Correct Answer: A
Rationale: The neonate is likely experiencing hypothermia with an axillary temperature below the normal range for a newborn. The best immediate action is to prevent further heat loss by wrapping the neonate warmly to maintain body temperature. Placing the neonate in an open crib will allow for better monitoring without the heat source of the radiant warmer. It is important to continue monitoring the neonate's temperature closely to ensure it returns to the normal range.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client's history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Pregnancy complicated with eclampsia at
- C. Spontaneous abortion at age 19 age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The human papillomavirus (HPV) infection is a major risk factor for cervical cancer. HPV is a sexually transmitted infection that is linked to almost all cases of cervical cancer. Therefore, a history of HPV infection increases the risk of developing cervical cancer. The other choices, such as onset of sexual activity at age 17, pregnancy complications, and spontaneous abortion, are not directly linked to an increased risk of cervical cancer.
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.