Nokea
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?
- A. Protect cornea with lubricant and eye shields
- B. Administer artificial tears every hour.
- C. Encourage the client to blink every 10 minutes.
- D. Keep the client's eyes closed with adhesive tape.
Correct Answer: A
Rationale: Lack of blinking increases the risk of corneal damage. Lubricants and eye shields prevent dryness and injury to the cornea.
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The following are causes of cyanosis in the presence of 60% oxygen:
- A. Haemoglobin concentration < 5 g%
- B. Methaemoglobinaemia
- C. Thalassaemia
- D. Right to left shunt
Correct Answer: D
Rationale: A right-to-left shunt can cause cyanosis even in the presence of high oxygen levels. Methaemoglobinaemia and severe anemia (Hb < 5 g%) can also cause cyanosis.
The following statements are true regarding a screening test:
- A. Sensitivity indicates the proportion of true positives
- B. Specificity indicates the proportion of true negatives
- C. Sensitivity is inversely related to specificity
- D. Prevalence affects predictive value
Correct Answer: D
Rationale: Prevalence affects predictive value
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
- A. Elevated temperature
- B. Generalized weakness
- C. Diminished lung sounds
- D. Pain when swallowing
Correct Answer: D
Rationale: Pain when swallowing could indicate an opportunistic infection such as candidiasis, which requires prompt treatment.
Concerning insulin-dependent diabetes mellitus in children:
- A. Microangiopathic changes are rare before puberty
- B. Isophane is shorter acting than soluble insulin
- C. Lipohypertrophy is more common than lipo-atrophy
- D. Fructosamine can be used to monitor glucose control
Correct Answer: A
Rationale: Microangiopathic changes are indeed rare before puberty in children with insulin-dependent diabetes mellitus. Isophane is not shorter acting than soluble insulin, and fructosamine is used to monitor glucose control.
Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply.)
- A. Atrial septal defects (ASDs)
- B. Tetralogy of Fallot
- C. Dextroposition of aorta
- D. Patent ductus arteriosus
Correct Answer: D
Rationale: The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.