Nokea
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: A
Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.
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Which of the following data would be included in a health history? (Select all that apply.)
- A. Review of systems
- B. Physical assessment
- C. Sexual history
- D. Growth measurements
Correct Answer: A
Rationale: A health history is a comprehensive compilation of information about a patient's health status, medical conditions, and pertinent background information. The selected data that would be included in a health history includes:
Which statement best describes the clinical manifestations of the preterm newborn?
- A. Head is proportionately small in relation to the body.
- B. Sucking reflex is absent, weak, or ineffectual.
- C. Thermostability is well established.
- D. Extremities remain in attitude of flexion.
Correct Answer: D
Rationale: The statement that best describes the clinical manifestations of the preterm newborn is that the extremities remain in an attitude of flexion. This characteristic is known as the "fetal position" and is commonly observed in preterm infants due to their premature musculoskeletal development. The flexed position of the extremities is a result of the baby's position in the uterus and is a normal finding for preterm newborns. Other clinical manifestations of preterm newborns may include a disproportionately large head in relation to the body, an immature or weak sucking reflex, and decreased thermostability due to their underdeveloped thermoregulatory systems.
A nurse is assessing a 5 year old with a history of heart failure. Which finding indicates that the child has adequate cardiac output?
- A. Urine output of 30 mL/h
- B. Heart rate of 120 beats/min
- C. Cap refill time of 10 to 15 sec
- D. Bilateral crackles heard on auscultation.
Correct Answer: A
Rationale: Adequate cardiac output is a measure of how well the heart is able to pump blood effectively to meet the body's metabolic demands. An adequate cardiac output ensures sufficient oxygen and nutrients are delivered to the tissues and organs. One of the most reliable indicators of adequate cardiac output is urine output. A urine output of at least 1 mL/kg/hour, which translates to around 30 mL/hour in a 5-year-old child, indicates adequate perfusion and renal function. In heart failure, decreased cardiac output may lead to decreased renal perfusion, resulting in a decreased urine output, so a stable or increased urine output suggests adequate cardiac output.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.