Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.
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Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: D
Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.
A 16-year-old male with cystic fibrosis is hospitalized for 2 weeks for IV antibiotics. Which action will most enhance his psychosocial development?
- A. Fax his teacher and have homework sent in.
- B. Encourage his friends to visit him in the hospital.
- C. Encourage frequent visits from his grandparents.
- D. Allow him unlimited phone use to contact friends.
Correct Answer: B
Rationale: Peer interactions are crucial during adolescence; having friends visit helps him feel connected and 'normal.'
A 16-year-old male with cystic fibrosis is hospitalized for 2 weeks for IV antibiotics. Which action will most enhance his psychosocial development?
- A. Fax his teacher and have homework sent in.
- B. Encourage his friends to visit him in the hospital.
- C. Encourage frequent visits from his grandparents.
- D. Allow him unlimited phone use to contact friends.
Correct Answer: B
Rationale: Peer interactions are crucial during adolescence; having friends visit helps him feel connected and 'normal.'
Stroking the newborn's cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
- A. Perez
- B. Sucking
- C. Rooting
- D. Extrusion
Correct Answer: C
Rationale: The described reflex involving stroking the newborn's cheek along the side of the mouth causing the newborn to turn the head toward that side and begin to suck is known as the rooting reflex. This reflex is essential for newborns to find the nipple and start breastfeeding. Stroking the cheek triggers the baby to turn towards the stimulus, helping them locate the source of food for feeding.
A patient is admitted for a splenectomy. Why is an injection of Vit. K ordered before surgery?
- A. To correct clotting problems
- B. To prevent postoperative infection
- C. To promote healing
- D. To dry secretions
Correct Answer: A
Rationale: Vitamin K plays a crucial role in the production of clotting factors in the liver. Patients undergoing a splenectomy may be at an increased risk of bleeding during and after surgery due to the decreased availability of these clotting factors. Administering Vitamin K before the surgery helps to correct any potential clotting problems, ensuring proper hemostasis and reducing the risk of excessive bleeding during the procedure. This preoperative intervention can help optimize the patient's coagulation status and improve their outcomes postoperatively.