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During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: During an ophthalmic assessment, the nurses are expected to observe the following carefully:
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. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Before undergoing a multigated acquisition scan, a client with suspected left sided heart failure should be medicated to relieve cough. Coughing can disrupt the accuracy of the scan results by affecting the heart's movement and leading to motion artifacts. Therefore, it is essential to address any coughing issues before the test to ensure reliable and accurate imaging of the heart's function. The other options, such as administering diuretics, avoiding fluid intake, and administering analgesics, are not directly related to optimizing the imaging quality of the multigated acquisition scan for a client with suspected left sided heart failure.
Which is the nurse's best interpretation of this?
- A. Resuscitation is likely to be needed.
- B. Adjustment to extrauterine life is adequate.
- C. Additional scoring in 5 more minutes is needed.
- D. Maternal sedation or analgesia contributed to the low score.
Correct Answer: B
Rationale: The nurse's best interpretation is that the adjustment to extrauterine life is adequate. This can be determined by the Apgar score, which assesses a newborn's well-being shortly after birth. A score of 7-10 indicates that the newborn is adjusting well to life outside the womb, while a score of 4-6 may indicate some difficulties that may require intervention. In this case, the nurse's interpretation suggests that the newborn is doing well in adapting to the new environment.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?
- A. At 1 to 2 years of age
- B. At I week to 1 year of age, peaking at 2 to 4 months
- C. At 6 months to 1 year of age, peaking at 10 months
- D. At 6 to 8 weeks of age
Correct Answer: B
Rationale: Sudden infant death syndrome (SIDS) is most likely to occur between the ages of 1 week to 1 year, with the highest risk period being between 2 to 4 months of age. While SIDS can occur up to the age of 1 year, the peak incidence is during the first 6 months of life. It is important to follow safe sleep practices, such as placing infants on their backs to sleep, to reduce the risk of SIDS during this vulnerable period.
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: Diagnostic study findings in multiple myeloma often include the presence of Bence Jones protein in the urine. Bence Jones protein is a type of abnormal protein (immunoglobulin light chain) produced by the abnormal plasma cells in multiple myeloma. Its presence in the urine can be detected through urine protein electrophoresis and is a characteristic feature of the disease. Other common findings in multiple myeloma include hypercalcemia, elevated serum creatinine level, and high serum protein level due to the excess production of monoclonal immunoglobulins.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: In a right-handed individual experiencing a stroke that affects the left side of the cortex, the deficits are typically seen on the opposite side of the body due to the way the brain is wired. This phenomenon is known as contralateral organization. In this scenario, the left side of the brain controls the right side of the body.