Nokea
A patient has a positive Homans' sign. Which of the ff. does the nurse understand explains why ambulation and performing the Homans' sign is now contraindicated?
- A. They can cause calf swelling c.They can cause an emboli
- B. They can cause patient pain
- C. They may cause a clot to form
Correct Answer: C
Rationale: A positive Homans' sign indicates possible deep vein thrombosis (DVT) in the leg. When a patient has DVT, the clot may dislodge and travel to the lungs, causing a pulmonary embolism, which can be life-threatening. Therefore, ambulation and performing the Homans' sign can dislodge the clot and potentially cause an embolism. It is contraindicated to prevent this serious complication.
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What should a nursing intervention to promote parent-newborn attachment include?
- A. Delaying parent-newborn interactions until the second period of reactivity
- B. Explaining individual differences among newborns to the parents
- C. Alleviating stress for parents by decreasing their participation in the newborn's care
- D. Allowing a newborn to fuss for a period of time before soothing by holding
Correct Answer: B
Rationale: A nursing intervention to promote parent-newborn attachment should include explaining individual differences among newborns to the parents. This is important because understanding a newborn's unique characteristics, behaviors, and needs can help parents feel more confident and responsive in caring for their baby. By educating parents about individual differences, nurses can empower them to create a strong bond with their newborn and provide appropriate care based on the baby's specific cues and signals. This can lead to a positive and nurturing parent-newborn relationship, which is crucial for the baby's development and well-being.
A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: Chemotherapy can cause fluid and electrolyte imbalances in the body, leading to potential kidney damage and altered urinary output. A low urine output of 400 ml in 8 hours could indicate dehydration or impaired renal function, both of which can be induced by chemotherapy. Monitoring urine output is crucial in assessing the patient's fluid balance and kidney function during chemotherapy. It is essential to identify and address such imbalances promptly to prevent complications.
Which is most important to document about immunizations in the child's health history?
- A. Dosage of immunizations received
- B. Occurrence of any reaction after an immunization
- C. The exact date the immunizations were received
- D. Practitioner who administered the immunizations
Correct Answer: C
Rationale: The most important information to document about immunizations in a child's health history is the exact date the immunizations were received. This information is crucial for tracking when the child is due for their next immunizations and to ensure they are following the recommended vaccination schedule. The dosage of immunizations received, occurrence of any reaction after an immunization, and the practitioner who administered the immunizations are also important details to document but the most critical one is the date to accurately maintain the vaccination records and plan future immunization appointments.
A 7 year old boy came to OPD with history of difficulty in rising up from sitting position. Examination reveals hypertrophy of calf muscles with trendelenburg gait. The most likely diagnosis is:
- A. Becker's muscular dystrophy
- B. Duchenne muscular dystrophy
- C. Myotonic muscular dystrophy
- D. Cerebral palsy
Correct Answer: B
Rationale: Duchenne muscular dystrophy typically presents in early childhood with difficulty rising from a seated position (Gower's sign), calf muscle hypertrophy, and Trendelenburg gait.
Undescended testis is a risk factor for the development of which of the following tumors?
- A. rhabdomyosarcoma
- B. leukemia
- C. yolk sac tumor
- D. lymphoma
Correct Answer: C
Rationale: Undescended testis is a well-documented risk factor for yolk sac tumors and other testicular cancers.