Nokea
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
- A. Rhine's test
- B. Pupillary reaction
- C. Romberg's test
- D. Patellar reflex
Correct Answer: C
Rationale: Romberg's test is a neurological test that assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception and vibration sensations. A lumbar injury can affect these dorsal columns, leading to impaired proprioception. Therefore, the Romberg's test would be affected due to the compromised sensory input from the lower extremities. This test usually involves asking the patient to stand with feet together and eyes closed to assess balance and proprioception.
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What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
- A. Avoid showering for 1 week.
- B. Sleep in a semi-fowler's position.
- C. Receive vaccines against infection.
- D. Stay on antibiotics for life.
Correct Answer: C
Rationale: Patients who have had a splenectomy are at increased risk for infections, particularly those caused by encapsulated bacteria such as Streptococcus pneumoniae. To prevent these infections, it is essential for these patients to receive vaccines against these bacteria. Vaccines recommended for patients who have had a splenectomy include the pneumococcal vaccine, meningococcal vaccine, and Hib vaccine. These vaccines help boost the body's immunity and provide protection against potentially life-threatening infections. It is important for healthcare providers to educate patients about the importance of receiving these vaccines to prevent infections post-splenectomy.
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
- A. Wash the area with soap and warm water
- B. Leave the skin alone until it is clear
- C. Apply a cream or lotion to the area
- D. Avoid applying creams or lotion to the area
Correct Answer: C
Rationale: Radio-dermatitis is a common side effect of radiation therapy, characterized by inflammation and irritation of the skin. Applying a cream or lotion to the affected area can help soothe the skin, reduce inflammation, and provide relief from symptoms such as itching and discomfort. It is important to choose a cream or lotion that is specifically designed for sensitive skin and recommended by healthcare professionals to ensure effectiveness and safety in managing radio-dermatitis. Washing the area with soap and warm water may further irritate the skin, while leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions may lead to dryness and further discomfort.
A nurse is preparing to test a school-age child's vision. Which eye chart should the nurse use?
- A. Denver Eye Screening Test
- B. Allen picture card test
- C. Ishihara vision test
- D. Snellen letter chart
Correct Answer: D
Rationale: The nurse should use the Snellen letter chart to test a school-age child's vision. The Snellen chart is specifically designed to assess distance vision by having the child read rows of letters of various sizes from a specific distance. This chart is commonly used for vision screenings and has standardized letter sizes that help determine visual acuity. The other options listed - Denver Eye Screening Test, Allen picture card test, and Ishihara vision test - are not typically used for testing visual acuity in the same way the Snellen chart is.
Neonates of mothers with diabetes are at risk for which complication following birth?
- A. Atelectasis
- B. Microcephaly
- C. Pneumothorax
- D. Macrosomia
Correct Answer: D
Rationale: Neonates of mothers with diabetes are at risk for macrosomia following birth. Macrosomia refers to a condition where the newborn baby is significantly larger than average, typically weighing more than 4,000 grams (8 pounds, 13 ounces) at birth. This risk is primarily due to maternal hyperglycemia, which can lead to excessive fetal growth. The elevated glucose levels in the maternal circulation can cross the placenta and stimulate fetal insulin production, resulting in increased growth and potentially leading to macrosomia. Neonates born with macrosomia are at increased risk for complications during delivery, such as shoulder dystocia, birth injuries, and the need for cesarean delivery.
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: Mastitis is an inflammatory condition of the breast tissue, often caused by an infection. Common symptoms of mastitis in a female client include swollen, firm, and hard breasts. These changes in breast tissue texture are indicative of inflammation and infection. Other possible signs of mastitis may include redness, warmth, and tenderness in the affected breast. The presence of swollen, firm, and hard breasts would confirm the diagnosis of mastitis in a female client.