Nokea
Fentanyl is used as analgesia during operative and postoperative procedures. Which of the following conditions is NOT associated with fentanyl use?
- A. Tachycardia
- B. Hypotension
- C. Nausea and vomiting
- D. Acidosis
Correct Answer: D
Rationale: Fentanyl typically causes hypotension, nausea, and vomiting, but it does not cause acidosis.
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The parents overhear that their child's tumor is stage III. They ask what that means. Which is the best response?
- A. The tumor is confined to the abdomen but has spread to lymph nodes or peritoneum; the prognosis is poor.
- B. The tumor is confined to the abdomen with spread to nearby lymph nodes or peritoneum; however, the prognosis remains very good.
- C. The tumor has spread to three other organs; the prognosis is good.
- D. The tumor has spread to other organs; the prognosis is poor.
Correct Answer: B
Rationale: Stage III indicates local spread (e.g., to lymph nodes or peritoneum) but still carries a very good prognosis with appropriate treatment.
The following are known to be causes of hepatitis except:
- A. virus
- B. toxin
- C. bacteria
- D. chemicals and drugs
Correct Answer: C
Rationale: Hepatitis is inflammation of the liver, and it can be caused by viruses, toxins, or chemicals and drugs. Bacteria, however, do not typically cause hepatitis. Common viral causes of hepatitis include hepatitis A, B, and C. Toxins like alcohol and certain medications, as well as exposure to chemicals, can also lead to hepatitis. Therefore, bacteria are not considered one of the primary causes of hepatitis.
When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: When assessing a client with a disorder of the hematopoietic or lymphatic system, obtaining a dietary history is important because compromised nutrition can interfere with the production of blood cells and hemoglobin. Hematopoiesis, the process of blood cell formation, requires adequate nutrition to support the production of red and white blood cells, as well as platelets. Nutrient deficiencies, such as iron, vitamin B12, and folate, can lead to anemia, which affects the oxygen-carrying capacity of red blood cells. Therefore, understanding the client's dietary intake can help the nurse identify any potential deficiencies or excessive intake that may be impacting hematopoiesis.
What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period called?
- A. Milia
- B. Lanugo
- C. Mongolian spots
- D. Cutis marmorata
Correct Answer: A
Rationale: Milia are distended sebaceous glands that appear as tiny white papules on the cheeks, chin, and nose in the newborn period. They are commonly found in newborns and usually resolve on their own without treatment. Milia are not harmful and are considered a normal physiological occurrence in newborns. Lanugo refers to fine, downy hair covering newborn infants, Mongolian spots are blue-grey birthmarks usually found on the lower back or buttocks of newborns, and Cutis marmorata is a vascular mottling of the skin in newborns.
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client's signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The client's signs and symptoms point towards a diagnosis of peritonitis, which is an inflammation of the peritoneum lining the abdominal cavity. The presence of severe, constant abdominal pain, rigid abdominal muscles, rebound tenderness, hypotension, and tachycardia are all indicative of peritonitis. These symptoms are typically seen when there is an infection or inflammation in the abdominal cavity, leading to fluid shifting from the intravascular space to the peritoneal cavity. This shifting of fluid results in hypovolemia, causing hypotension and tachycardia.