Nokea
The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?
- A. Normal
- B. Erythema
- C. Jaundice
- D. Ecchymosis
Correct Answer: C
Rationale: Jaundice is the yellow discoloration of the skin, sclera (white part of the eyes), soles of feet, and palms of hands that occurs due to elevated levels of bilirubin in the blood. Bilirubin is a yellow pigment produced during the breakdown of red blood cells and is normally processed by the liver and excreted in bile. When the liver is unable to process bilirubin effectively, it can accumulate in the blood and cause jaundice. Therefore, the nurse should document these findings as jaundice, which is a sign of liver dysfunction or other underlying health issues that need further assessment and management.
You may also like to solve these questions
A 1-year-old child develops right eye ptosis, miosis, and loss of sweating; you suspect neuroblastoma. The MOST valuable investigation to confirm the diagnosis is
- A. CT scan of the neck and chest
- B. CT scan of the abdomen
- C. CT scan of the brain
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: A
Rationale: CT scan of the neck and chest can help identify a primary neuroblastoma mass in the adrenal gland or sympathetic chain.
Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client's pulse rate every hour
Correct Answer: B
Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
- A. Apply a cold compress to the injured eye
- B. Apply a light bandage to the eye
- C. perform an assessment on the client
- D. flush the eye continuously with sterile solution
Correct Answer: D
Rationale: The first action should be to flush the eye continuously with a sterile solution to remove the chemical and prevent further damage to the eye. This is important in cases of chemical burns to prevent the chemical from causing more harm or spreading to other parts of the eye. It is crucial to start immediate irrigation to promote the best possible outcome and help alleviate the pain and potential long-term damage. Once the eye has been thoroughly flushed, further assessment and appropriate treatment can be provided by the healthcare team.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The signs and symptoms mentioned in option A are indicative of potential complications that may occur in a patient being monitored by a nurse.
A school nurse is conducting a class with adolescents on suicide. Which true statement about suicide should the nurse include in the teaching session?
- A. A sense of hopelessness and despair are a normal part of adolescence.
- B. Gay and lesbian adolescents are at a particularly high risk for suicide.
- C. Problem-solving skills are of limited value to the suicidal adolescent.
- D. Previous suicide attempts are not an indication of risk for completed suicides.
Correct Answer: B
Rationale: Gay and lesbian adolescents are at a particularly high risk for suicide. Research has shown that sexual minority youth, such as gay, lesbian, bisexual, and transgender adolescents, are at a higher risk for suicide due to the stress, discrimination, and lack of acceptance they may face. It is important for the school nurse to address the unique risk factors and challenges faced by LGBTQ+ adolescents when discussing suicide prevention in order to provide appropriate support and resources.