Nokea
In the presence of coma or unconsciousness, the major therapeutic measure includes:
- A. Maintenance of a clear airway
- B. Good nursing care
- C. Retention of catheter
- D. All of the above
Correct Answer: A
Rationale: In the presence of coma or unconsciousness, maintaining a clear airway is the major therapeutic measure to ensure adequate breathing and oxygenation. A clear airway is vital for the patient's survival and should be the priority to prevent respiratory distress or failure. Providing good nursing care is important for overall patient well-being, but ensuring a clear airway is crucial for immediate life support. Retention of a catheter is not a major therapeutic measure in the context of coma or unconsciousness unless specifically indicated for monitoring or treatment of underlying conditions. Therefore, the most critical intervention in this scenario is the maintenance of a clear airway.
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The nurse is teaching about congenital clubfoot in infants. The nurse evaluates the teaching as successful when the parent states that clubfoot is best treated when?
- A. Immediately after diagnosis.
- B. At age 4 to 6 months.
- C. Prior to walking (age 9 to 12 months).
- D. After walking is established (age 15 to 18 months).
Correct Answer: A
Rationale: Congenital clubfoot is best treated when started immediately after diagnosis. Early intervention and treatment are crucial for better outcomes in correcting clubfoot deformities. Tendons and ligaments are more flexible in infants, making it easier to manipulate and correct the foot. Starting treatment as early as possible can help prevent long-term complications and improve the child's ability to walk normally. Therapy may involve stretching exercises, casting, or surgery, depending on the severity of the condition. Therefore, early intervention is key in the successful management of congenital clubfoot in infants.
The MOST appropriate answer to why infants cry in response to another infant's cry is
- A. an early sign of empathy development
- B. a sign of good hearing reflex
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Empathy begins developing early, though rudimentary.
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: The most important assessment for the nurse to make first in this situation is the client's blood pressure. Abrupt discontinuation of prednisone, especially in a client with lupus erythematosus, can lead to adrenal insufficiency or an Addisonian crisis. Addisonian crisis can present with symptoms such as severe hypotension, fatigue, weakness, and even shock. Therefore, monitoring the client's blood pressure is crucial to assess for signs of adrenal insufficiency and to intervene promptly if needed. Once blood pressure is assessed, the nurse can then proceed to assess other parameters such as breath sounds, capillary refill, and the presence of a butterfly rash.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The signs and symptoms mentioned in option A are indicative of potential complications that may occur in a patient being monitored by a nurse.
An inborn error of metabolism that causes a premature destruction of RBC?
- A. G6PD
- B. Homocystinuria
- C. Phenylketonuria
- D. Celiac Disease
Correct Answer: A
Rationale: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inborn error of metabolism that leads to the premature destruction of red blood cells (hemolysis). G6PD is an enzyme responsible for protecting red blood cells from oxidative damage. In individuals with G6PD deficiency, the red blood cells are more susceptible to oxidative stress, leading to their destruction and resulting in hemolytic anemia. This condition is commonly triggered by certain medications, infections, or dietary factors that cause oxidative stress, leading to hemolysis. Homocystinuria, Phenylketonuria, and Celiac Disease are metabolic disorders that do not typically result in the premature destruction of red blood cells.