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 answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals.
Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.
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During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client’s lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: The correct answer is B: Discuss the negative feelings with the client. This is the most appropriate action as it allows the nurse to address and manage their own biases and attitudes towards the client in a professional and constructive manner. By acknowledging and discussing these feelings with the client, the nurse can work towards providing non-judgmental care and fostering a therapeutic relationship.
A: Sharing these feelings with the client is not appropriate as it can harm the nurse-client relationship and potentially lead to discrimination.
C: Developing a written interview form is not addressing the immediate issue of the nurse's negative attitude towards the client.
D: Avoiding eye contact with the client is unprofessional and does not address the underlying issue of the nurse's negative feelings.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
Blood cells are formed in the:
- A. Arterioles
- B. Lymphoid tissue
- C. Bone marrow
- D. Muscle tissue
Correct Answer: C
Rationale: The correct answer is C: Bone marrow. Blood cells are primarily formed in the bone marrow through a process called hematopoiesis. The bone marrow contains stem cells that differentiate into various types of blood cells, including red blood cells, white blood cells, and platelets. Arterioles are small blood vessels that carry blood away from the heart, not involved in blood cell formation. Lymphoid tissue plays a role in immune function but not in blood cell production. Muscle tissue is primarily responsible for movement and does not have a role in blood cell formation. Therefore, the bone marrow is the correct answer as it is the main site of blood cell production in the body.
Bell’s palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: The correct answer is B: 7th cranial nerve. Bell's palsy is caused by inflammation of the facial nerve (7th cranial nerve), leading to facial muscle weakness or paralysis. The 3rd cranial nerve (choice A) controls eye movement, the 5th cranial nerve (choice C) is responsible for facial sensation and chewing, and the 8th cranial nerve (choice D) is related to hearing and balance. Bell's palsy specifically affects the facial muscles, making choice B the correct answer.