Nokea
As the nurse cares for a patient with angioedema, differs from urticaria in that angioedema is characterized by which of the following?
- A. Angioedema is more pruritic.
- B. Angioedema has small, fluid-filled vesicles
- C. Angioedema has a deeper and more that crust.
- D. Angioedema lasts a shorter time.
Correct Answer: C
Rationale: Angioedema differs from urticaria in that it involves deeper layers of the skin and subcutaneous tissue compared to urticaria, which affects the upper layers of the skin. This deeper involvement in angioedema can lead to swelling that appears as large, raised areas that often have a deeper hue compared to the surrounding skin. Angioedema does not typically involve small, fluid-filled vesicles like urticaria, and it is not necessarily more pruritic. Additionally, angioedema tends to last longer than urticaria, which is why option D is not accurate.
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The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
- A. Limit visits by family members
- B. Encourage the client to use a wheelchair
- C. Use the smallest needle possible for injections
- D. Maintain accurate fluid intake and output records Situation: AIDS cases has been all over the country and yet only few are reported cases due to the stigma attach to it.
Correct Answer: C
Rationale: Thrombocytopenia is a condition characterized by a low platelet count in the blood, which can lead to abnormal bleeding and bruising. Using the smallest needle possible for injections helps minimize the risk of causing bleeding or bruising in clients with thrombocytopenia. Larger needles can cause more tissue damage and increase the chances of bleeding complications in these individuals. Therefore, using the smallest needle possible is the best way to protect the client from potential harm related to their condition.
While assessing a newborn infant for developmental hip dysplasia (DDH), the nurse evaluates which of the following signs as indicating the presence of DDH?
- A. One knee is lower when both legs are flexed
- B. Thigh and gluteal skin folds are symmetrical
- C. Hip adduction of affected side is limited
- D. Negative Ortolani sign when hips are abducted
Correct Answer: A
Rationale: In developmental hip dysplasia (DDH), one knee appearing lower than the other when both legs are flexed indicates a possible dislocated hip joint or hip dysplasia. This finding is known as the Galeazzi sign and is often used as a clinical indicator for DDH in newborn infants. It suggests a discrepancy in leg lengths due to hip instability or malformation. Therefore, this sign is important in helping to diagnose DDH and initiating appropriate interventions early on.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?
- A. Indicates they live in poverty
- B. Is lacking in protein
- C. May provide sufficient amino acids
- D. Should be enriched with meat and milk
Correct Answer: C
Rationale: The nurse should assess that the diet of the Hispanic family, which consists mainly of vegetables, legumes, and starches, may provide sufficient amino acids. While this diet may lack animal sources of protein commonly found in meat and milk, plant-based foods like legumes and grains can complement each other to provide all essential amino acids necessary for protein synthesis in the body. This combination of foods essentially forms a complete protein source, supporting overall nutritional needs. It's important for the nurse to recognize the potential nutritional value in the diet and offer education on balanced meal planning to ensure adequate protein intake for the family. The assessment should focus on the overall nutrient adequacy and not solely on the presence of specific food items.
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
- A. Rhine's test
- B. Pupillary reaction
- C. Romberg's test
- D. Patellar reflex
Correct Answer: C
Rationale: Romberg's test is a neurological test that assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception and vibration sensations. A lumbar injury can affect these dorsal columns, leading to impaired proprioception. Therefore, the Romberg's test would be affected due to the compromised sensory input from the lower extremities. This test usually involves asking the patient to stand with feet together and eyes closed to assess balance and proprioception.
When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence?
- A. The acne has not responded to other treatments.
- B. The adolescent is or may become pregnant.
- C. The adolescent is unable to give up foods causing acne.
- D. Frequent washing with antibacterial soap has been unsuccessful.
Correct Answer: A
Rationale: Isotretinoin (Accutane) is a potent medication used for severe acne that has not responded to other treatments, such as topical medications or antibiotics. It is typically considered as a last resort due to its potential side effects and risks. Adolescents with resistant, severe acne who have not seen improvement with other therapies may be good candidates for isotretinoin treatment. It is important for the prescribing healthcare provider to carefully assess the severity of the acne and weigh the benefits against the potential risks before initiating isotretinoin therapy.