Nokea
An infant develops jaundice 6 hours after birth. Which one of the following is the most likely diagnosis?
- A. Haemolytic disease of the newborn.
- B. Umbilical sepsis.
- C. Physiological jaundice.
- D. Atresia of the bile ducts.
Correct Answer: A
Rationale: Jaundice within 24 hours of birth is pathological, often due to haemolytic disease of the newborn (A), such as Rh incompatibility causing rapid red cell breakdown. Physiological jaundice (C) typically appears after 24 hours, while umbilical sepsis (B), bile duct atresia (D), and neonatal hepatitis (E) are less likely to cause such early onset.
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A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.
Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.
A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which the most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the abuser?
- A. Voluntary individual or group therapy
- B. Court-ordered individual or group therapy
- C. Voluntary couples or family therapy
- D. None of the above
Correct Answer: A
Rationale: The correct answer is A: Voluntary individual or group therapy. This type of therapy would be most helpful as it focuses on addressing the abuser's personal issues and behaviors, such as managing frustration and anger. By participating voluntarily, the abuser is more likely to be open to introspection and change.
Summary of other choices:
B: Court-ordered therapy may not be as effective as voluntary therapy, as the abuser may feel forced and less motivated to engage in the process.
C: Couples or family therapy may not be appropriate initially as the abuser needs to work on personal issues first before addressing relationship dynamics.
D: None of the above is incorrect as voluntary individual or group therapy is the most suitable option for addressing the abuser's behavior.
A priority measure to teach a client who purges is:
- A. that purging endangers one's health.
- B. that individuals who are overweight can be well-adjusted.
- C. to seek out a trusted person when feeling the need to purge.
- D. to use laxatives rather than vomiting as a way to eliminate food.
Correct Answer: C
Rationale: Rationale: Choice C is correct because seeking out a trusted person when feeling the need to purge can help the client establish a supportive and healthy coping mechanism. It encourages open communication, emotional support, and accountability. This approach addresses the underlying issues contributing to the purging behavior, fostering long-term positive change. Choices A, B, and D are incorrect as they do not directly address the need for seeking support and establishing healthier coping strategies.
Which nursing diagnosis is most appropriate for a patient with bulimia nervosa who engages in frequent purging behaviors?
- A. Ineffective coping related to inability to control impulses.
- B. Risk for injury related to electrolyte imbalances.
- C. Imbalanced nutrition: less than body requirements related to food refusal.
- D. Disturbed body image related to fear of weight gain.
Correct Answer: B
Rationale: The correct answer is B: Risk for injury related to electrolyte imbalances. Patients with bulimia nervosa who engage in frequent purging behaviors are at risk for electrolyte imbalances due to loss of potassium, sodium, and other essential minerals. This can lead to serious complications such as cardiac arrhythmias and organ damage. Monitoring and addressing electrolyte imbalances is crucial in the care of these patients to prevent potential harm.
A: Ineffective coping related to inability to control impulses is not the most appropriate diagnosis as it does not directly address the immediate risk of electrolyte imbalances in this scenario.
C: Imbalanced nutrition: less than body requirements related to food refusal is not the most appropriate diagnosis as the primary concern in bulimia nervosa with purging behaviors is the risk of electrolyte imbalances, not necessarily inadequate food intake.
D: Disturbed body image related to fear of weight gain is not the most appropriate diagnosis as it does not address the immediate physical health risks
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
- A. saying, 'These are your clothes. Please get dressed.'
- B. saying, 'These are your underpants. I'll help you put them on.'
- C. asking, 'Which of these two outfits would you like to wear now?'
- D. asking, 'Is something the matter with your clothes that makes you not want to dress?'
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy.
Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.