Nokea
The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The best evidence that the teaching has been effective is when the patient uses an electric razor instead of his safety razor. This action demonstrates understanding and application of the teaching to prevent bleeding in a practical way. By choosing the electric razor, the patient is actively taking steps to minimize the risk of injury and bleeding due to thrombocytopenia. This concrete behavior indicates that the patient has internalized the instructions provided by the nurse and is implementing them to protect his health.
You may also like to solve these questions
Which of the ff nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest c.Elevate the clients head
- B. Administer a prescribed anti pyretic
- C. Administer supplemental oxygen
Correct Answer: C
Rationale: Administering supplemental oxygen is the most appropriate nursing intervention to relieve tachycardia that may develop in a client with myocarditis from hypoxemia. Myocarditis can lead to decreased oxygen delivery to the tissues, which may result in tachycardia as the body tries to compensate for the lack of oxygen. Providing supplemental oxygen will help increase oxygen levels in the blood, improving tissue perfusion and thus reducing the tachycardia. This intervention aims to address the underlying cause of the tachycardia in this situation.
What is the Guthrie blood test use to diagnose in the newborn?
- A. Down syndrome
- B. Isoimmunization
- C. PKU
- D. Congenital hypothyroidism (CH)
Correct Answer: C
Rationale: The Guthrie blood test, also known as the newborn screening test, is used to diagnose phenylketonuria (PKU) in newborns. PKU is an inherited metabolic disorder in which the body cannot properly process the amino acid phenylalanine. If left untreated, PKU can lead to intellectual disabilities and other serious health problems. The Guthrie blood test is a simple and effective way to detect PKU early so that treatment can begin promptly to prevent complications.
Laboratory studies indicate a client's blood pressure level is 185mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most occlusive diagnostic information about the client's glucose utilization?
- A. A fasting blood glucose test
- B. A test of serum glycosylated hemoglobin (HbA1c)
- C. A 6-hour glucose tolerance test
- D. A test for urine ketones
Correct Answer: C
Rationale: A 6-hour glucose tolerance test would yield the most occlusive diagnostic information about the client's glucose utilization in this case. The elevated blood pressure level of 185 mg/dL two hours after breakfast indicates poor glucose regulation. A glucose tolerance test involves monitoring the client's blood glucose levels over a period of time after ingesting a glucose solution. This test provides a comprehensive assessment of how the body processes glucose, revealing any abnormalities in glucose metabolism beyond fasting levels, such as postprandial (after-meal) glucose spikes and prolonged hyperglycemia. This can help identify conditions like insulin resistance, impaired glucose tolerance, or diabetes, which may not be evident from a fasting blood glucose test alone. Glycosylated hemoglobin (HbA1c) reflects average blood sugar levels over the past 2-3 months and would not provide immediate information about the client's current glucose metabolism. Urine ketones
the frontal fontanell is protruding when a child suffering from:
- A. meningitis
- B. hydrocepalus
- C. subdural hematoma
- D. all the answers are correct
Correct Answer: D
Rationale: The protrusion of the frontal fontanelle in a child can be a concerning sign and can be seen in various conditions such as meningitis, hydrocephalus, and subdural hematoma. In meningitis, the inflammation of the meninges can lead to increased intracranial pressure, which may cause the fontanelle to bulge. Hydrocephalus, which is the buildup of fluid in the brain, can also result in the fontanelle being more pronounced. Additionally, a subdural hematoma, which is a collection of blood between the brain and its outermost covering, can lead to pressure on the brain and consequent fontanelle protrusion. Therefore, all the provided choices (A, B, C) are correct as they can lead to the protrusion of the frontal fontanelle in a child.
Regarding the gross motor skills, a 2-year-old child can
- A. heel-toe walk
- B. balance on each foot 6 sec
- C. walk up and down stairs
- D. balance well on each foot
Correct Answer: C
Rationale: A 2-year-old typically can walk up and down stairs with support.