Nokea
In a conscious trauma patient with a suspected head injury, which of the following actions is appropriate?
- A. Applying direct pressure to the wound.
- B. Administering aspirin for pain relief.
- C. Maintaining cervical spine immobilization.
- D. Assessing pupil reaction to light.
Correct Answer: C
Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.
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If more than one vaccine is given, the following guidelines should be observed, EXCEPT.
- A. Do not give more than one dose of the same vaccine in one session.
- B. Do not use the same arm or leg for more than one injection.
- C. Give doses of the same vaccine at the correct intervals.
- D. Use the same syringe and needle in administering two vaccines.
Correct Answer: D
Rationale: It is NOT recommended to use the same syringe and needle in administering two different vaccines. This is to prevent contamination or mixing of different vaccines, which could potentially affect their effectiveness or pose a risk to the individual receiving the vaccines. It is important to use separate syringes and needles for each vaccine to ensure proper administration and prevent any adverse reactions.
If a research study involves an intervention and "blinding" which research design is being referred to?
- A. Non-descriptive
- B. Experimental
- C. Phenomenological
- D. Descriptive
Correct Answer: B
Rationale: The research design being referred to in the question is an experimental design. An experimental study involves the manipulation of an independent variable, which is the intervention in this case, to determine its effect on a dependent variable. "Blinding" in research refers to the practice of withholding information about the intervention from certain individuals involved in the study, such as researchers, participants, or outcome assessors. Blinding is commonly used in experimental studies to reduce bias and ensure the integrity of the study results. This combination of intervention and blinding is a hallmark of experimental research designs.
A patient presents with chest pain, dyspnea, and a friction rub heard on auscultation. An electrocardiogram (ECG) shows diffuse ST-segment elevation. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Pericarditis
Correct Answer: D
Rationale: The clinical presentation of chest pain, dyspnea, and a friction rub heard on auscultation is suggestive of pericarditis. The diffuse ST-segment elevation seen on the electrocardiogram (ECG) is a classic finding in pericarditis, known as the "universal sign." In contrast, stable angina typically presents with chest pain on exertion that is relieved by rest or nitroglycerin, while unstable angina presents with chest pain at rest or with minimal exertion. Acute myocardial infarction would typically present with ST-segment elevation in specific leads correlating with the area of myocardial ischemia/infarction. However, in the context of diffuse ST-segment elevation and symptoms suggestive of inflammation (friction rub), the most likely diagnosis is pericarditis.
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.
Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
- A. Rapid progressive muscular atrophy.
- B. Ascending paralysis with ataxia .
- C. Hyperactive deep tendon reflexes
- D. Paresthesia and muscle weakness of upper body.
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.