Nokea
Idiopathic thrombocytopenic purpura (ITP) commonly results in what finding?
- A. Blood clots
- B. Pallor
- C. Dry membranes
- D. Bruising
Correct Answer: D
Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, leading to an increased risk of bleeding and easy bruising. Platelets are responsible for blood clotting and when their count is low, it can result in purpura (bruising) due to small blood vessels leaking blood into the skin. For this reason, the most common finding in ITP is bruising rather than blood clots, pallor, or dry membranes.
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Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: In a post-operative patient, sudden chest heaviness can be a sign of various complications, such as a pulmonary embolism or cardiac issue. One of the immediate nursing interventions for a patient complaining of chest heaviness is to ensure adequate oxygenation. Administering oxygen via a face mask can help improve oxygenation and provide relief while further assessments are being done to determine the cause of the symptom. This intervention takes priority over documenting the symptom, offering analgesics, or informing the physician, as addressing the patient's oxygen needs is crucial in this situation.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.
Which of the following types of cells is the immune system's shutoff mechanism?
- A. Plasma cells
- B. Suppressor T cells
- C. Helper T cells
- D. B lymphocytes
Correct Answer: B
Rationale: Suppressor T cells, also known as regulatory T cells, play a critical role in regulating the immune response by acting as the immune system's shutoff mechanism. These cells help maintain immune tolerance and prevent overactivation of the immune system, thereby preventing autoimmune reactions and excessive inflammation. Suppressor T cells exert their immunosuppressive effects by inhibiting the function of other immune cells, such as effector T cells and B cells, and helping to control the overall balance of the immune system.
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: Inability to move the affected leg after a lumbar microdiskectomy could indicate a serious complication such as nerve damage or postoperative hematoma putting pressure on the nerves. This is a critical issue that should be reported to the physician immediately for proper evaluation and management to prevent further complications or permanent damage. The other options, such as incisional pain, bleeding on the dressing, or muscle spasm, are common postoperative issues that may not require immediate medical attention unless they are severe or persistent.
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
- A. Hypotension and Bradycardia
- B. Tachypnea and retractions
- C. Acrocyanosis and grunting
- D. The presence of a barrel chest with grunting
Correct Answer: B
Rationale: Respiratory distress syndrome (RDS), also known as hyaline membrane disease, is a condition commonly seen in preterm newborn infants. The two classic signs of RDS are tachypnea (rapid breathing) and retractions. Tachypnea is defined as a respiratory rate greater than 60 breaths per minute in newborn infants. Retractions refer to visible indrawing of the chest wall with each breath, indicating increased work of breathing. These signs are indicative of the infant's struggle to breathe and can suggest the presence of RDS. While acrocyanosis (bluish discoloration of the extremities) and grunting may also be present in infants with RDS, tachypnea and retractions are more specific indicators of respiratory distress. Hypotension and bradycardia are not common signs of RDS. The presence of a barrel chest with grunting is not specific