Nokea
An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to
- A. clean the umbilical cord with Betadine to prevent infection
- B. give the baby a bath
- C. call the laboratory to collect a PKU screening test
- D. check the baby's serum glucose level and administer glucose if < 40 mg/dL
Correct Answer: D
Rationale: The priority of care when a baby born to an insulin-dependent diabetic mother is brought to the nursery is to check the baby's serum glucose level and administer glucose if it is less than 40 mg/dL. Babies born to diabetic mothers, especially those with poorly controlled blood sugar levels, are at risk for hypoglycemia (low blood sugar) due to the sudden drop in glucose supply after delivery. Hypoglycemia can be dangerous for newborns and can lead to serious complications if left untreated. Therefore, monitoring the baby's serum glucose levels and providing appropriate intervention, such as administering glucose if necessary, is critical to ensure the baby's well-being.
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Children with ALL who carry poor outcome include all the following EXCEPT
- A. age younger than 1 year and older than 10 year
- B. T-cell immunophenotype
- C. hyperdiploidy chromosomal abnormality
- D. initial leukocyte count of > 50,000
Correct Answer: C
Rationale: Hyperdiploidy is generally associated with a favorable prognosis in ALL, unlike other listed factors.
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client's lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: It is important for the nurse to acknowledge and address any negative feelings or biases that may arise during patient care, especially when caring for a patient with a stigmatized condition like HIV/AIDS. Discussing these negative feelings with a trusted colleague, such as the charge nurse, can help the nurse process and overcome their biases in a safe and non-judgmental environment. By addressing these feelings, the nurse can ensure that they provide compassionate and professional care to the patient and their partner without any personal biases interfering with the care delivery. Sharing these feelings with the client or avoiding eye contact would be inappropriate and counterproductive to establishing trust and providing care. Developing a written interview form would not address the underlying issue of negative attitudes or biases and may not be effective in promoting unbiased care.
The nurse knows that Parkinson's disease a progressive neurologic disorder is characterized by:
- A. Bradykinesia
- B. Tremor
- C. Muscle rigidity
- D. All of the above
Correct Answer: D
Rationale: Parkinson's disease is a progressive neurologic disorder that is characterized by a triad of symptoms known as the classic Parkinsonian triad. These symptoms include bradykinesia (slowness of movement), tremor (involuntary shaking), and muscle rigidity (stiffness of the muscles). Therefore, all of the given choices are correct in describing the characteristics of Parkinson's disease.
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: Option D is the most appropriate statement when assisting a patient with altered thought process and personal hygiene needs. This statement provides the patient with a choice between brushing their teeth independently or having assistance, while also emphasizing the importance of self-care activities. Offering patients choices empowers them and helps maintain their sense of autonomy, even when dealing with altered thought processes. Additionally, encouraging patients to perform activities for themselves can help improve their self-esteem and promote independence.