Nokea
Mr Balao asks the nurse as to the source of this disease. The nurse is aware that this is a disease of:
- A. connective tissue
- B. Bones
- C. purine metabolism Situation- Mr Gil age 86 years, has been diagnosed with Alzheimer's disease.
Correct Answer: A
Rationale: Alzheimer's disease is a neurodegenerative disease that primarily affects the brain, not connective tissue or bones. It is characterized by the accumulation of abnormal protein aggregates in the brain, leading to loss of cognitive function and memory. The nurse would be aware that Alzheimer's disease does not involve bones or purine metabolism, making connective tissue the correct answer in this context.
You may also like to solve these questions
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
- A. axilla
- B. upper arms
- C. elbows
- D. hands
Correct Answer: C
Rationale: When using crutches after an above the knee amputation, it is important for the client to support their weight primarily on their elbows. Placing the weight on the elbows helps to prevent pressure on the axilla (armpit area), which can lead to nerve damage and discomfort. Supporting weight on the elbows also provides better stability and control while using crutches, allowing the client to move more safely and comfortably. Additionally, distributing the weight onto the elbows helps to avoid potential strain and injury to the hands or upper arms.
The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?
- A. Place in Trendelenburg position periodically.
- B. Suction at least every 2 to 3 hours.
- C. Maintain neutral thermal environment.
- D. Hyperextend neck with nose pointing to ceiling.
Correct Answer: C
Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.
Which of the following medications can be used to quickly reduce SOB in a crisis situation for a patient with end-stage respiratory disease?
- A. Oral cortisone
- B. IV morphine
- C. IM meperidine (Demerol)
- D. IV propanolol (Inderal)
Correct Answer: B
Rationale: IV morphine is the most appropriate choice among the options provided for quickly reducing shortness of breath (SOB) in a crisis situation for a patient with end-stage respiratory disease. Morphine is commonly used in palliative care for symptom management in patients with severe respiratory distress. It acts as a respiratory depressant by reducing the perception of breathlessness, which can help alleviate the distressing symptoms of dyspnea. The rapid onset of action of IV morphine makes it an effective option for immediate relief in emergency situations for patients experiencing significant SOB due to end-stage respiratory disease. Oral cortisone, IM meperidine (Demerol), and IV propranolol (Inderal) are not primary choices for quickly reducing SOB in this context.
The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis. What knowledge should the nurse's response be based on?
- A. Genetic defect
- B. Birth injury
- C. Spinal cord injury
- D. Inborn error of metabolism
Correct Answer: B
Rationale: Facial nerve paralysis in a newborn is most commonly caused by birth injury. This can occur during the birthing process due to pressure on the baby's face or head, particularly if forceps or vacuum extraction are used during delivery. The trauma can affect the facial nerve resulting in temporary or permanent paralysis. It is important for the nurse to provide reassurance to the parents that birth injury is a common cause of facial nerve paralysis in newborns, and in many cases, the paralysis resolves on its own over time without further complications.