Nokea
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until color returns to normal
Correct Answer: D
Rationale: Monitoring is appropriate as the symptoms are consistent with Raynaud's phenomenon and should resolve with warming.
You may also like to solve these questions
In embryology:
- A. Most defects occur with teratogens in the first 2 weeks post-conception
- B. The urachus becomes the median umbilical ligament
- C. The mesonephric duct becomes the male organs
- D. The thyroid develops from the floor of the primitive larynx
Correct Answer: B
Rationale: The urachus becomes the median umbilical ligament. Most defects occur after the first 2 weeks, and the thyroid develops from the floor of the pharynx.
All the following statements about spontaneous coronary artery dissection are true, except
- A. More common in young females
- B. Proximal coronary involvement associated with immuno-inflammatory disease
- C. Intra-coronary imaging shows 'accordion sign'
- D. Physical stress precipitates it by causing intimal tear
Correct Answer: C
Rationale: The 'accordion sign' is not typically associated with spontaneous coronary artery dissection.
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.
Diagnostic signs of child abuse are:
- A. Sub-hyaloid bleeding
- B. Spiral fracture of a long bone
- C. Lacerated tongue
- D. Posterior rib fractures
Correct Answer: D
Rationale: Posterior rib fractures are highly suggestive of child abuse, as they are often caused by forceful squeezing or shaking.
Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?
- A. Patch one eye and then the other every few hours
- B. Encourage bedrest until the diplopia is resolved
- C. Instruct the client to limit intake of oral fluids
- D. Administer artificial tear drops to both eyes
Correct Answer: A
Rationale: Patching each eye helps alleviate double vision caused by MS-related vision impairment.