Nokea
A young couple of a 2-month-old baby girl with excessive crying seeks medical advice. The LEAST important advice is to
- A. master the situation in a relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing the milk formula is less critical unless there is evidence of intolerance or allergy.
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Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?
- A. Measure intake and output
- B. Perform the mini-mental status
- C. Use the Glasgow Coma scale examination
- D. Assess vital signs
Correct Answer: A
Rationale: Monitoring intake and output is essential in assessing for electrolyte imbalances and dehydration in a client with a neurologic deficit. Unlike options B, C, and D, measuring intake and output provides direct information on the client's fluid balance and kidney function. Electrolyte imbalances can lead to neurological complications and alterations in mental status, making it crucial to keep track of the amounts of fluids ingested and excreted by the client. Additionally, dehydration can exacerbate neurological deficits, so monitoring intake and output can help prevent this complication.
Which of the following procedures does the nurse understand is used to correct otosclerosis?
- A. Myringotomy
- B. Mastoidectomy
- C. Myringoplasty
- D. Stapedectomy
Correct Answer: D
Rationale: Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, particularly around the stapes bone. A stapedectomy is a surgical procedure performed to correct otosclerosis by removing the stapes bone and replacing it with a prosthesis. This surgery aims to improve hearing by restoring the movement of the ossicles in the middle ear. Myringotomy is a procedure involving an incision in the eardrum to drain fluid, mastoidectomy involves the removal of infected mastoid air cells, and myringoplasty is the surgical repair of a perforated eardrum, none of which address the specific issue of otosclerosis.
Hepatoblastoma is a neoplasm of undifferentiated precursors of hepatocytes. It is of different histological classification; which type predict the MOST favorable outcome?
- A. mixed type of pure epithelial and mesenchymal elements
- B. type of pure epithelial histology
- C. type of mixed fetal and embryonal histology
- D. type of undifferentiated histology
Correct Answer: B
Rationale: Pure epithelial histology, particularly fetal type, is associated with the best prognosis.
Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen?
- A. Daily use of an antibiotic
- B. Pulse rate less than 50 beats/minute
- C. Normal weight for age
- D. Elevation in red blood cell (RBC) count
Correct Answer: C
Rationale: In a young child like Clay who is diagnosed with heart failure, following the directed therapeutic regimen would involve maintaining a normal weight for his age. Weight monitoring is crucial in managing heart failure as excessive weight gain could lead to worsening of symptoms and complications. Ensuring that Clay stays within a normal weight range for his age shows his adherence to dietary recommendations, fluid restrictions, and overall treatment plan aimed at managing his heart failure effectively. Monitoring his weight would also help healthcare providers assess if the treatment plan is working and make necessary adjustments as needed. Therefore, Clay maintaining a normal weight for his age indicates that he is strictly following the directed therapeutic regimen for his heart failure.
What is the best initial action for the nurse to take?
- A. Try to have the client breathe slower or
- B. Give O2 via nasal cannula into the paper bag
- C. Administer sodium bicarbonate
- D. Monitor the client's fluid balance
Correct Answer: A
Rationale: The best initial action for the nurse to take when a client is experiencing hyperventilation is to try to have the client breathe slower. This is because hyperventilation is often caused by rapid, shallow breathing and slowing down the breathing pattern can help restore normal gas exchange and alleviate symptoms. Providing oxygen via a nasal cannula or administering sodium bicarbonate would not directly address the underlying issue of hyperventilation. Monitoring fluid balance is important for overall assessment but not the priority when dealing with acute respiratory distress due to hyperventilation.