Nokea
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
- A. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
- B. Gently raise Mr. Gabatan to a sitting position to see if the pain either
- C. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available
- D. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
Correct Answer: C
Rationale: The correct initial action in this scenario would be to roll Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available. This position is known as the recovery position, and it is important for individuals who have suspected spinal injuries. By rolling Mr. Gabatan onto his abdomen, it helps protect his spine and prevent further injury. Placing a pad under his head provides some support, and covering him with material helps to keep him warm and comfortable while waiting for additional help to arrive. It is crucial to avoid movement, especially if there is a suspected spinal injury, as moving the individual incorrectly can worsen the injury and lead to permanent damage.
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In an individual with Sjogren's syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: Sjogren's syndrome is an autoimmune disorder characterized by dryness of the eyes and mouth due to the destruction of moisture-producing glands. Nursing care for individuals with Sjogren's syndrome should focus on addressing the symptoms related to dryness. Moisture replacement is key in managing dry eyes and dry mouth, which can improve the patient's comfort and quality of life. Strategies for moisture replacement may include the use of artificial tears, saliva substitutes, and humidifiers to maintain adequate hydration and alleviate dryness. Nutritional supplementation, electrolyte balance, and arrhythmia management are not typically the primary focus of nursing care in individuals with Sjogren's syndrome.
Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: A
Rationale: In the preoperative phase, one of the key roles of a nurse in patient care is to obtain preoperative orders. This involves ensuring that all necessary tests, medications, and procedures are in place before the surgery is performed. By obtaining preoperative orders, the nurse ensures that the patient is adequately prepared for the surgical procedure and that any potential risks or complications are minimized. This role requires attention to detail, clear communication with the healthcare team, and a thorough understanding of the patient's individual needs and medical history.
Prenatal screening is recommended for all pregnant women to detect neural tube defect. If a neural tube defect is present, one of the following is often elevated
- A. human chorionic gonadotropin
- B. a-fetoprotein
- C. estriol
- D. inhibin
Correct Answer: B
Rationale: Alpha-fetoprotein (AFP) levels are elevated in maternal serum when a neural tube defect is present due to fetal leakage of AFP into the amniotic fluid and maternal circulation.
Baby Melody is a neonate who has a very low-birth-weight. Nurse Josie carefully monitors inspiratory pressure and oxygen (O ) concentration to prevent which of the following?
- A. Meconium aspiration syndrome
- B. Bronchopulmonary dysplasia (BPD)
- C. Respiratory syncytial virus (RSV)
- D. Respiratory distress syndrome (RDS)
Correct Answer: D
Rationale: A neonate with very low birth weight is at risk of developing respiratory distress syndrome (RDS), which is a common breathing disorder in premature infants. RDS occurs due to a lack of a substance in the lungs called surfactant, which helps keep the air sacs open and prevents them from collapsing. In neonates with very low birth weight, the lungs may not have produced enough surfactant, leading to breathing difficulties and respiratory distress.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, leading to a slowing down of the body's metabolic processes. One of the hallmark symptoms of hypothyroidism is extreme fatigue or tiredness. This can be due to the overall decrease in metabolic rate affecting energy levels and causing a feeling of exhaustion. Other common symptoms of hypothyroidism include weight gain, cold intolerance, constipation, dry skin, and depression. Tachycardia (fast heart rate), hyperthermia (elevated body temperature), and weight loss are not typically associated with hypothyroidism, but rather with conditions such as hyperthyroidism where there is an excess of thyroid hormone production.