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A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
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A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
- A. A-positive blood to an A-negative client
- B. O-positive blood to an A-positive client
- C. O-negative blood to an O-positive client
- D. B-positive blood to an AB-positive client
Correct Answer: B
Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
- A. 8 mm Hg
- B. 25 mm Hg
- C. 11 mm Hg
- D. 28 mm Hg
Correct Answer: C
Rationale: Normal intraocular pressure (IOP) typically ranges between 10 and 21 mm Hg. For this reason, the tonometer measurements of 11 mm Hg and 20 mm Hg fall within the normal range. Therefore, clients with these IOP values (Option C and E) have normal intraocular pressure. The other options (A, B, and D) are outside the normal range for IOP and are therefore considered elevated.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, "I don't understand how this medication works. Will it stop the infection?" What is the nurse's best response?
- A. The medication helps to slow the disease process, but it won't cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don't you know? There aren't medication to stop or cure HIV
- D. No. it won't stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The nurse's best response is, "The medication blocks reverse transcriptase, the enzyme required for HIV replication." This response provides the client with a clear and accurate explanation of how zidovudine (AZT) works. AZT is a nucleoside reverse transcriptase inhibitor (NRTI) that works by blocking the activity of reverse transcriptase, an enzyme needed for HIV replication. By inhibiting this enzyme, AZT helps to slow down the replication of the virus, reducing the viral load in the body and slowing the progression of the disease. It is important for the client to understand that while AZT can help manage HIV/AIDS, it is not a cure and will not completely eliminate the infection.
Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
- A. prevent bleeding.
- B. enhance immune response.
- C. prevent bacterial infection.
- D. maintain nutritional status.
Correct Answer: A
Rationale: Vitamin K is essential for the production of clotting factors in the liver. Newborns have lower levels of vitamin K and may not have a fully functioning clotting system, putting them at risk for bleeding disorders such as vitamin K deficiency bleeding (VKDB). Administering vitamin K to newborns helps prevent these bleeding issues and ensures proper clotting function. It does not have a direct effect on enhancing the immune response, preventing bacterial infections, or maintaining nutritional status, as its primary function in this context is to prevent bleeding disorders.