Nokea
A common chronic complication of diabetes due to the thickening of the capillaries and arterioles of the eye is?
- A. Papilledema
- B. Glaucoma
- C. Retinal Detachment
- D. Diabetic retinopathy
Correct Answer: D
Rationale: The correct answer is D: Diabetic retinopathy. This condition is a common complication of diabetes that occurs due to the thickening of capillaries and arterioles in the eye, leading to damage to the retina. This can result in vision problems and even blindness if left untreated.
A: Papilledema is the swelling of the optic disc due to increased intracranial pressure, not related to diabetes.
B: Glaucoma is a condition characterized by increased pressure within the eye, not directly caused by diabetes.
C: Retinal detachment is the separation of the retina from the underlying tissues, which is not primarily caused by diabetes-related capillary changes.
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In providing tracheostomy care which of the following is the nurse's PRIORITY nursing action? The nurse ________.
- A. Cuts the dressing using sterile scissors
- B. Clean the incisions with iodine-based antiseptic
- C. Secures clean ties before removing soiled ones
- D. Uses clean technique
Correct Answer: C
Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.
A 20-year-old woman presents with sudden onset of severe lower abdominal pain and missed menstrual periods for the past two months. She has a positive urine pregnancy test. On transvaginal ultrasound, an empty uterus is visualized, and there is fluid in the cul-de-sac. Which condition is most likely to be responsible for these findings?
- A. Ovarian cyst rupture
- B. Ectopic pregnancy
- C. Septic abortion
- D. Ovarian torsion
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. In this scenario, the combination of missed periods, positive pregnancy test, and empty uterus on ultrasound with fluid in the cul-de-sac is highly suggestive of an ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, commonly in the fallopian tube. The presence of fluid in the cul-de-sac indicates possible blood from a ruptured ectopic pregnancy, causing the severe lower abdominal pain. Ovarian cyst rupture (A) typically presents with less severe pain. Septic abortion (C) would present with signs of infection and products of conception in the uterus. Ovarian torsion (D) would present with acute onset of unilateral lower abdominal pain and a palpable adnexal mass, not fluid in the cul-de-sac.
There is an outbreak of measles in some areas of the community where Nurse Rona is assigned. Which of the following-steps of an outbreak investigation should Nurse Rona and her team begin ?
- A. Identify and count cases.
- B. Define and identify cases.
- C. Verify diagnosis
- D. Prepare for field work.
Correct Answer: A
Rationale: The correct answer is A: Identify and count cases. In the initial stages of an outbreak investigation, it is crucial to identify and count cases to understand the scope and magnitude of the outbreak. By counting cases, Nurse Rona and her team can track the spread of the disease, identify common characteristics among those affected, and determine the extent of the outbreak. This step helps in guiding further investigation and control measures.
Summary of other choices:
B: Define and identify cases - While defining cases is important, it is not the initial step in outbreak investigation.
C: Verify diagnosis - Verifying diagnosis is important but comes after identifying and counting cases.
D: Prepare for field work - Field work is important in outbreak investigations, but it typically comes after the initial step of identifying and counting cases.
The physician prescribes decongestant intranasal spray. The nurse instructs the client on the proper use of the spray. Which of the following procedures is the CORRECT method?
- A. Finish instillation of spray into one nostril before spraying into the other nostril
- B. Inhale quickly to prevent irritation off the mucous membranes
- C. Blow the nose after spraying to prevent medications from entering the throat
- D. Tilt the head slightly forward and angle the bottle toward the side of the nostril
Correct Answer: D
Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat.
Choices A, B, and C are incorrect:
A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness.
B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray.
C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.
The nurse is aware that which occurrence in the patient 's health history suggests the diagnosis of GBS?
- A. viral illness few weeks before
- B. encephalitis
- C. severe bacterial infection
- D. meningitis
Correct Answer: A
Rationale: The correct answer is A because a viral illness few weeks before can trigger Guillain-Barre Syndrome (GBS) due to the body's immune response attacking the peripheral nerves. Encephalitis (B), severe bacterial infection (C), and meningitis (D) are not directly linked to GBS pathophysiology. Viral infections are known to precede GBS development, making choice A the most appropriate option.