Nokea
A healthcare professional is screening patients for immunizations. Which of the following is not a contraindication for immunization?
- A. Seizures
- B. Fever lasting more than 3 days
- C. Malignancy within the past 3 months
- D. Illness lasting more than 6 months
Correct Answer: D
Rationale: The correct answer is D, 'Illness lasting more than 6 months.' Chronic conditions lasting more than 6 months are not considered a contraindication for immunization. Choice A, 'Seizures,' can be a contraindication in certain situations, especially if linked to a specific vaccine component. Choice B, 'Fever lasting more than 3 days,' can be a temporary precaution but not a general contraindication. Choice C, 'Malignancy within the past 3 months,' is a contraindication due to the compromised immune system in cancer patients.
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When teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?
- A. Use a soft toothbrush.
- B. Use dental floss daily.
- C. Hold pressure on any scrapes for 1-2 minutes.
- D. Use a triple-edged razor.
Correct Answer: A
Rationale: The correct answer is to 'Use a soft toothbrush.' A soft toothbrush is recommended because it is less likely to cause the gums to bleed in clients with leukemia, who are at risk of bleeding due to overcrowding of white cells at the expense of other cell types like platelets. Choice B, 'Use dental floss daily,' is incorrect because dental floss is contraindicated and can make the gums bleed in clients with leukemia. Choice C, 'Hold pressure on any scrapes for 1-2 minutes,' is incorrect because when clotting is impaired, pressure should be held for 5-10 minutes or longer until the bleeding stops. Choice D, 'Use a triple-edged razor,' is incorrect because an electric razor should be used instead of a triple-edged razor to prevent small cuts and bleeding in clients with leukemia.
A 55-year-old female asks a nurse the following, “Which mineral/vitamin is the most important to prevent the progression of osteoporosis?†The nurse should state:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Vitamin B12
Correct Answer: C
Rationale: The correct answer is C: Calcium. Calcium is essential for maintaining bone health and is crucial in preventing osteoporosis. Adequate calcium intake, along with vitamin D, is vital for bone strength. While other minerals and vitamins are also important for overall health, in the context of preventing osteoporosis, calcium plays a primary role. Potassium (Choice A), Magnesium (Choice B), and Vitamin B12 (Choice D) are important for various bodily functions but are not as directly linked to preventing osteoporosis as calcium.
A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short-term memory
- C. Babinski sign
- D. Clonus sign
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.
A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct Answer: A
Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
- A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
- B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
- C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
- D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus
Correct Answer: B
Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).
Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest.
Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production.
Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.