Nokea
A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.
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A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance of promptly starting and completing the entire course of antibiotics.
- A. alleviate painful swallowing to avoid complications of dehydration and malnutrition'
- B. prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas'
- C. reduce the risk of anterior cervical lymphadenopathy'
- D. eliminate organisms that might initiate acute renal failure or rheumatic fever'
Correct Answer: D
Rationale: The correct answer is D. Completing the entire course of antibiotics for strep throat is crucial to eliminate the bacteria completely. Failure to do so may lead to potential complications like acute renal failure or rheumatic fever, which are serious systemic conditions associated with untreated strep infections. This is because streptococcal infections can trigger an immune response that can attack other parts of the body if not fully eradicated.
Choice A is incorrect because while completing the antibiotics may alleviate painful swallowing, the main emphasis should be on preventing systemic complications. Choice B is incorrect as sinusitis or abscess formation are not the primary concerns with strep throat. Choice C is incorrect as reducing anterior cervical lymphadenopathy is not the primary goal of antibiotic treatment for strep throat.
In summary, completing the full course of antibiotics is crucial to eliminate the bacteria and prevent serious complications such as acute renal failure or rheumatic fever.
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.
At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?
- A. The skin is wrinkled and fat is being formed.
- B. The eyelids are open and he can see.
- C. The kidneys are making urine.
- D. The heart is being developed.
Correct Answer: C
Rationale: Correct Answer: C - The kidneys are making urine.
Rationale: At 10 weeks gestation, the kidneys of the developing fetus begin to form and function, producing urine. This is a crucial milestone in fetal development as it indicates proper organ formation and functionality. The formation of urine by the kidneys plays a significant role in maintaining the amniotic fluid levels and supporting overall fetal growth and development.
Summary of other choices:
A: The skin is wrinkled and fat is being formed - Incorrect. Skin and fat formation typically occur later in gestation, not at 10 weeks.
B: The eyelids are open and he can see - Incorrect. Eye development is still in progress at 10 weeks, and the eyelids remain fused.
D: The heart is being developed - Incorrect. While the heart is forming at 10 weeks, it is not the most accurate response to the question posed by the primigravida.