Nokea
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
- A. Prevent strenuous exercises by the client
- B. Use pressure relieving devices when the client is in bed
- C. Place the client in Fowler's position
- D. Avoid giving daily baths with soaps to the client
Correct Answer: B
Rationale: Using pressure relieving devices when the client is in bed is essential to prevent skin breakdown. Clients with neuromuscular disorders are at higher risk for impaired skin integrity due to limited mobility and sensation. Pressure relieving devices such as specialized mattresses, cushions, or pads help distribute pressure evenly and reduce the risk of pressure ulcers. Maintaining good skin integrity is crucial in preventing complications and promoting the overall well-being of the client. It is important for the nurse to assess the client's risk factors, implement preventive measures like using pressure relieving devices, and monitor the client's skin regularly to prevent skin breakdown.
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Which of the following types of translocation of childhood AML that typically associated with granulocytic sarcoma mass?
- A. inv(16)
- B. t(8;21)
- C. t(6;9)
- D. inv(3)
Correct Answer: A
Rationale: The inv(16) translocation is strongly associated with granulocytic sarcoma in AML.
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
- A. Naturally acquired active immunization
- B. Artificially acquired passive
- C. Artificially acquired active immunization immunization
- D. Passive immunization
Correct Answer: D
Rationale: Passive immunization involves the administration of pre-formed antibodies rather than stimulating the individual's immune system to produce its own antibodies (active immunization). In the case of a pregnant client requiring immediate but temporary protection from chickenpox, passive immunization would be the most appropriate choice. This is because passive immunization can provide immediate protection without activating the pregnant individual's immune system, which could pose potential risks during pregnancy. By introducing pre-formed antibodies against chickenpox, the pregnant client can acquire temporary immunity to the virus, safeguarding both her and her developing baby.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
Which screening test for colorectal cancer should the nurse recommend?
- A. Carcinoembryonic antigen (CEA) test
- B. Annual digital examination after age 50
- C. Barium enema after age 50
- D. Proctosigmoidoscopy after age 50
Correct Answer: D
Rationale: The nurse should recommend a proctosigmoidoscopy for colorectal cancer screening in individuals over the age of 50. This procedure allows for the visualization of the lower part of the colon and rectum, which are common sites for precancerous and cancerous lesions to develop. Proctosigmoidoscopy can help identify abnormalities early on, allowing for prompt intervention and treatment. This screening method helps in detecting colorectal cancer or pre-cancerous polyps at an early stage when they are more easily treatable. Regular screening is essential for early detection and prevention of colorectal cancer. Other screening tests such as carcinoembryonic antigen (CEA) test, annual digital examination, and barium enema are not recommended as primary screening methods for colorectal cancer.
A nurse is preparing to accompany a medical mission's team to a third world country. Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition?
- A. Loose, wrinkled skin
- B. Edematous skin
- C. Depigmentation of the skin
- D. Dermatoses
Correct Answer: A
Rationale: Marasmus is a form of severe malnutrition characterized by a significant deficiency in calories and protein intake. Symptoms of marasmus include severe wasting of muscle and fat stores, giving the appearance of loose, wrinkled skin due to the loss of subcutaneous fat. Other symptoms may include lethargy, irritability, delayed growth and development, and weakened immune function. Edematous skin is more commonly associated with kwashiorkor, another form of severe malnutrition characterized by protein deficiency with adequate caloric intake. Depigmentation of the skin and dermatoses are not typical symptoms of marasmus.