Nokea
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
- A. encourages the guest to eat some
- B. call the guest's personal hygiene
- C. offer the guest a peppermint
- D. give the guest a glass of orange juice
Correct Answer: D
Rationale: The best action for the nurse to take in this situation is to give the guest a glass of orange juice (Choice D). The guest is most likely experiencing hypoglycemia (low blood sugar) due to diabetes. Orange juice contains natural sugars that can help raise the guest's blood sugar levels quickly. Since the guest is feeling dizzy and trembling, providing a source of fast-acting sugar like orange juice is crucial in addressing the low blood sugar and preventing the situation from worsening. It is important to follow up with a source of longer-lasting carbohydrates and protein after the guest's blood sugar levels have stabilized.
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A 1-year-old child develops right eye ptosis, miosis, and loss of sweating; you suspect neuroblastoma. The MOST valuable investigation to confirm the diagnosis is
- A. CT scan of the neck and chest
- B. CT scan of the abdomen
- C. CT scan of the brain
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: A
Rationale: CT scan of the neck and chest can help identify a primary neuroblastoma mass in the adrenal gland or sympathetic chain.
Which vitamin is recommended for all women of childbearing age to reduce the risk of neural tube defects such as spina bifida?
- A. A
- B. C
- C. Niacin
- D. Folic acid
Correct Answer: D
Rationale: Folic acid is the correct answer. All women of childbearing age are recommended to take folic acid to reduce the risk of neural tube defects such as spina bifida in their offspring. Neural tube defects occur in the early stages of pregnancy, often before a woman even knows she is pregnant, which is why it is important for all women of childbearing age to ensure they have adequate folic acid intake. Folic acid is a B vitamin that helps the body make new cells and plays a crucial role in the development of the baby's neural tube, which eventually becomes the brain and spinal cord. Adequate folic acid intake before and during pregnancy can significantly reduce the risk of neural tube defects. That's why it is recommended for all women of childbearing age to take a daily folic acid supplement or consume foods fortified with folic acid.
Which of the ff. subjective data questions would assist the nurse in assessing the patient's eye health?
- A. "Have you had any recent upper respiratory infections?"
- B. "Have you ridden in a car recently?"
- C. "Have you been scuba diving lately?"
- D. "Have you seen halos around lights?"
Correct Answer: D
Rationale: This question specifically pertains to visual disturbances and can provide valuable information about the patient's eye health. Seeing halos around lights can indicate increased intraocular pressure, which could be a sign of conditions such as glaucoma. Therefore, this subjective data question would assist the nurse in assessing the patient's eye health. On the other hand, choices A, B, and C are not directly related to eye health and would not provide relevant information in assessing the patient's eyes.
Which nursing diagnosis is most appropriate for a client with Addison's disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: Addison's disease is a condition characterized by adrenal insufficiency, resulting in a deficiency of aldosterone and cortisol. Without aldosterone, the body is unable to regulate fluid and electrolyte balance properly, leading to sodium loss and potassium retention. This imbalance can result in excessive fluid volume, as the kidneys retain water and sodium. Symptoms of excessive fluid volume in Addison's disease can include edema, weight gain, and hypertension. Therefore, the most appropriate nursing diagnosis for a client with Addison's disease would be Excessive Fluid Volume.
Primary amenorrhea should be considered for any female adolescent who has not reached menarche by
- A. 13 years or has not done so within 3 years of thelarche
- B. 14 years or has not done so within 2 years of thelarche
- C. 14 years or has not done so within 3 years of thelarche
- D. 15 years or has not done so within 3 years of thelarche
Correct Answer: D
Rationale: Primary amenorrhea is suspected if menarche has not occurred by age 15 or within 3 years of thelarche.