Nokea
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: Following a splenectomy, the client's hemoglobin level of 7.5g/dl indicates anemia, which can contribute to orthostatic hypotension. When the client changes position from lying to standing, the decrease in blood volume may lead to a drop in blood pressure. Additionally, the compensatory mechanism to maintain perfusion to vital organs is to increase the heart rate. Therefore, the vital sign values that would most support the nurse's analysis are a drop in blood pressure (hypotension) and a rise in heart rate (tachycardia).
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Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
- A. 1st
- B. 7th
- C. 5th
- D. 8th
Correct Answer: C
Rationale: Tic douloureux, also known as trigeminal neuralgia, is a disorder of the 5th cranial nerve. This condition is characterized by intense, sharp, stabbing, and burning pain that follows the distribution of one or more branches of the trigeminal nerve. The pain occurs in short, sudden attacks or paroxysms, typically triggered by touching specific trigger points or by activities such as eating or speaking. It is important to correctly identify and diagnose the involvement of the 5th cranial nerve in such cases to provide appropriate treatment options for the patient.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To prevent respiratory obstruction
- C. To help the client drink fluids
- D. To prevent excessive bleeding
Correct Answer: B
Rationale: An ice collar may be ordered for a client undergoing drainage of a peritonsillar abscess to prevent respiratory obstruction. Peritonsillar abscess is a collection of pus behind the tonsils, and the inflammation and swelling from the abscess can lead to difficulty in breathing or swallowing. Applying an ice collar can help reduce the swelling and prevent the abscess from compressing the airway, thus reducing the risk of respiratory obstruction. It can provide comfort to the client and support the drainage process by minimizing the swelling and promoting better drainage of the abscess.
A 3-week-old neonate is brought to the emergency department because of a three-day history of intermittent vomiting. His mother reports that he has not urinated for eight hours. On physical examination, his eyes are sunken. Which of the following will MOST likely require correction before surgery is performed?
- A. Hypochloremia
- B. Hyperkalemia
- C. Hypernatremia
- D. N/A
Correct Answer: A
Rationale: Hypochloremia is often associated with dehydration and metabolic alkalosis, which may need correction before surgery.
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.
Which vitamin is recommended for all women of childbearing age to reduce the risk of neural tube defects such as spina bifida?
- A. A
- B. C
- C. Niacin
- D. Folic acid
Correct Answer: D
Rationale: Folic acid is the correct answer. All women of childbearing age are recommended to take folic acid to reduce the risk of neural tube defects such as spina bifida in their offspring. Neural tube defects occur in the early stages of pregnancy, often before a woman even knows she is pregnant, which is why it is important for all women of childbearing age to ensure they have adequate folic acid intake. Folic acid is a B vitamin that helps the body make new cells and plays a crucial role in the development of the baby's neural tube, which eventually becomes the brain and spinal cord. Adequate folic acid intake before and during pregnancy can significantly reduce the risk of neural tube defects. That's why it is recommended for all women of childbearing age to take a daily folic acid supplement or consume foods fortified with folic acid.