Nokea
Complete bed rest What is the most common congenital heart disease?
- A. ASD
- B. TOF
- C. VSD
- D. CHF
Correct Answer: C
Rationale: The most common congenital heart disease is Ventricular Septal Defect (VSD). VSD is a heart condition present at birth where there is a hole in the wall (septum) separating the lower chambers of the heart (ventricles). This hole allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle, leading to increased pulmonary blood flow and potentially causing complications such as pulmonary hypertension and right ventricular hypertrophy. VSD can be classified as an acyanotic heart defect with a left to right shunt. Treatment options for VSD include monitoring, medications, and in some cases, surgical intervention.
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Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- A. Romberg test
- B. Caloric test
- C. Otoscopic examination
- D. Whisper voice test
Correct Answer: D
Rationale: The nurse would use the whisper voice test as an initial screening test to determine hearing loss. This test involves the nurse whispering a series of words or numbers from a distance behind the patient to assess their ability to hear and repeat the whispered words accurately. This test is quick, easy, and can be performed in a quiet environment without the need for special equipment, making it an effective initial screening tool for hearing loss. The Romberg test assesses balance, the caloric test evaluates vestibular function, and the otoscopic examination is used to assess the external ear canal and eardrum, but none of these tests specifically assess hearing loss.
A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions?
- A. Shampoo every three days with a mild soap.
- B. The hair should be shampooed with a medicated shampoo.
- C. Shampoo every day with an antiseborrheic shampoo.
- D. The loosened crusts should not be removed with a fine-toothed comb.
Correct Answer: A
Rationale: The nurse should include in the instructions to shampoo every three days with a mild soap. Seborrheic dermatitis, commonly known as cradle cap in infants, is a common condition characterized by greasy, yellowish, scaly patches on the scalp. Mild cases of cradle cap typically do not require aggressive treatment. Using a mild soap and shampooing every few days can help loosen the scales and prevent buildup without causing irritation to the infant's delicate skin. It is important not to shampoo too frequently or use harsh products as this can exacerbate the condition. Additionally, the loosened crusts can be gently massaged and removed after shampooing with a soft brush or cloth, but it is not necessary to use a fine-toothed comb, as this may cause skin irritation.
The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
- A. Meconium
- B. Transitional
- C. Miliaria
- D. Milk stool
Correct Answer: A
Rationale: Meconium is the term used to describe the first stool of a newborn. This stool is black and tarry in appearance. Meconium is made up of materials ingested by the fetus while in the uterus, such as mucus, amniotic fluid, and cells shed from the stomach and intestines. It is typically passed by a newborn within the first few days of life before transitioning to transitional stools, which are greenish-brown in color, and eventually to normal milk stools as the baby starts feeding on breast milk or formula.
Increased intracranial pressure can cause which of the following?
- A. seizure
- B. nausea
- C. vomiting
- D. all of the above
Correct Answer: D
Rationale: Increased intracranial pressure (ICP) can cause a variety of symptoms, including seizures, nausea, and vomiting. When the pressure inside the skull rises, it can put pressure on the brain tissue, leading to changes in normal brain function. Seizures may occur as a result of the altered brain activity. Nausea and vomiting can also be triggered by increased ICP, as the body's natural response to the disturbance in the brain's normal functioning. Therefore, all of the listed options (seizure, nausea, vomiting) can be caused by increased intracranial pressure.
Nurse Katriz is planning a client education program for sickle cell disease (SCD); what topics should be included in the plan of care?
- A. Aerobic exercise to improve oxygenation
- B. Fluid restraint to 1 qt (1 L)/day
- C. A high-iron, high-protein diet
- D. Proper hand washing and infectionavoidance
Correct Answer: D
Rationale: People with sickle cell disease (SCD) are at a higher risk of infections due to their impaired immune system. Infections can trigger a sickle cell crisis, which can be life-threatening. Therefore, proper hand washing and infection avoidance are crucial components of the care plan for clients with SCD. This topic should be included in Nurse Katriz's client education program to help reduce the risk of infections and promote better health outcomes for individuals with SCD.