During what period of gestation do congenital heart defects usually develop?
- A. First 8 weeks of gestation
- B. Second trimester
- C. Third trimester
- D. Last 4 weeks of gestation
Correct Answer: A
Rationale: Congenital heart defects typically develop during the first 8 weeks of gestation when the baby's heart is forming. This is a critical period of organogenesis, where the heart undergoes complex development and any disruptions during this time can lead to structural abnormalities in the heart. Factors such as genetics, environmental influences, and certain maternal health conditions can contribute to the development of congenital heart defects during this early stage of pregnancy. It is crucial for mothers to receive proper prenatal care to help reduce the risk of congenital heart defects and other birth abnormalities.
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A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis?
- A. Place the client in low-Fowler position to improve gas exchange
- B. Monitor the client's oxygen saturation intermittently
- C. Encourage frequent amulation
- D. Use continuous endotracheal suctioning instead of coughing and deep breathing
Correct Answer: B
Rationale: Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.
The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client?
- A. Infection
- B. Fluid volume
- C. Peripheral perfusion
- D. Sleep pattern
Correct Answer: C
Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.
A patient is scheduled for an electromyogram. What should the nurse instruct the patient to do in preparation for this diagnostic test? Select all that apply.
- A. Do not smoke for 3 hours before the test
- B. Avoid taking muscle relaxants before the test
- C. Avoid taking oral hypoglycemic agents before the test
- D. Alert the healthcare provider about an allergy to shellfish e. Avoid fluids containing caffeine for 3 hours before the test
Correct Answer: B
Rationale: B. It is essential for the patient to avoid taking muscle relaxants before the electromyogram test because these medications can affect the results by altering muscle activity and electrical signals, which are critical for diagnosing muscle and nerve disorders.
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
- A. Slight increase in pulse
- B. Dry, warm skin
- C. Increased urine output
- D. Normal respirations
Correct Answer: A
Rationale: A. A slight increase in pulse is a common finding in hypovolemic shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain adequate perfusion.
The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?
- A. Caucasians have an increased incidence of intracerebral hemorrhage.
- B. African Americans have almost twice the number of first-ever strokes compared with Whites.
- C. Asian Americans are more likely to die following a stroke than Whites.
- D. The prevalence of hypertension among Hispanics is the highest in the world.
Correct Answer: B
Rationale: The correct statement that should be included in the presentation is that African Americans have almost twice the number of first-ever strokes compared with Whites. This is based on research and statistics that show African Americans have a higher incidence of stroke compared to other ethnic groups in the United States. It is important for healthcare providers to be aware of these disparities in order to address them effectively through targeted prevention and management strategies. Moreover, raising awareness about these risk factors can help promote early intervention and reduce the burden of stroke within the African American community.