Nokea
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The client's symptoms of dizziness upon standing up, along with nosebleeds and blurred vision, are suggestive of postural hypotension. Postural hypotension, also known as orthostatic hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, blurred vision, and in some cases, nosebleeds. It is more common in older adults, like the 78-year-old male client in this scenario. Therefore, the nurse should assess for postural hypotension in this client to manage his symptoms and prevent complications.
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The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. "Never suction your tracheostomy; you might damage your trachea."
- B. ""You should not feel bad about the tracheostomy – you should be feel lucky to be alive."
- C. "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals."
- D. "Your tracheostomy will be cleaned each time you visit your doctor."
Correct Answer: C
Rationale: Option C, "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals," is the most appropriate instruction for a patient with a new tracheostomy. It is important to keep the tracheostomy site clean and free from any potential irritants or contaminants that could cause infection or complications. Powders, hair, and chemicals can lead to irritation or clogging of the tracheostomy tube, so it is crucial for the patient to be mindful of avoiding such pollutants near the tracheostomy site.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
- A. Poor control of blood glucose levels
- B. Current of recent foot trauma
- C. Inappropriate foot care
- D. Advanced age
Correct Answer: D
Rationale: Advanced age is a nonmodifiable risk factor for diabetes mellitus. Nonmodifiable risk factors are characteristics or traits that cannot be changed or controlled. In this case, a person's age is a factor that continuously increases as time passes and cannot be altered. Other nonmodifiable risk factors for diabetes mellitus include family history of diabetes and certain ethnic backgrounds. On the other hand, poor control of blood glucose levels, current or recent foot trauma, and inappropriate foot care are examples of modifiable risk factors that can be managed through lifestyle changes and proper medical care.
Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity?
- A. A sudden drop in blood pressure
- B. Insufficient cerebral oxygenation
- C. Decreased level of serum glucose
Correct Answer: B
Rationale: Anemia is a condition characterized by a decreased number of red blood cells or hemoglobin, which can result in inadequate oxygen delivery to tissues and organs, including the brain. When Aisa engages in physical activity, her body's oxygen demand increases. However, due to her anemia, there is a reduced capacity to transport oxygen to meet the increased demand. This mismatch between oxygen supply and demand leads to insufficient oxygen reaching her brain, resulting in dizziness. This symptom is consistent with the explanation of insufficient cerebral oxygenation in the context of anemia.
A 10-mo-old boy has a left suprarenal mass. Surgery is accomplished with complete removal of the mass as well as the non-adherent lymph nodes; surgical biopsies are taken during surgery. The histology reveals poorly differentiated neuroblastoma with microscopic ipsilateral lymph nodes involvement. The contralateral lymph nodes are negative. Of the following, the BEST therapeutic approach for this infant is
- A. chemotherapy
- B. radiotherapy
- C. concomitant chemo-radiotherapy
- D. chemotherapy followed by radiotherapy
Correct Answer: A
Rationale: Complete resection with microscopic residual disease typically warrants adjuvant chemotherapy.
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
- A. Activate the code blue or emergency system
- B. Do nothing because acrocyanosis is normal in the neonate
- C. Immediately take the newborn's temperature according to hospital policy
- D. Notify the physician of the need for a cardiac consult
Correct Answer: B
Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.