Nokea
Mr. Santos a 59-year old businessman was diagnosed with angina pectoris. The nurse understands that the cause of angina pectoris is:
- A. decrease in the alveolar surface for gas exchange
- B. inadequate supply of oxygen to the myocardium
- C. inadequate blood pressure in the pulmonary circulation
- D. increase in the alveolar surface for gas exchange
Correct Answer: B
Rationale: Angina pectoris is chest pain or discomfort caused by a temporary lack of an adequate blood supply to the heart muscle (myocardium). This lack of blood supply results in a decreased supply of oxygen to the heart muscle, leading to chest pain. This condition is commonly associated with coronary artery disease, where the arteries that supply blood to the heart become narrowed or blocked, reducing the flow of oxygen-rich blood to the myocardium. This oxygen deficit can trigger chest pain, which is characteristic of angina pectoris. Therefore, the cause of angina pectoris is the inadequate supply of oxygen to the myocardium, making option B the correct answer.
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While Andres is being assessed at the clinic, Nurse Shiela observed that the child appears to be small, with an immature face and chubby body build. Her parents stated that their child's rate of growth of all body parts is somewhat slow, but her proportions and intelligence remain normal. As a knowledgeable nurse, you know that the child has a deficiency of which of the following?
- A. Antidiuretic hormone (ADH)
- B. Parathyroid hormone (PTH)
- C. Growth hormone (GH)
- D. Melanocyte-stimulating hormone (MSH)
Correct Answer: C
Rationale: The child described in the scenario displays characteristics consistent with growth hormone deficiency. Growth hormone is essential for the growth and development of bones, muscles, and other tissues in the body. A deficiency in growth hormone can result in growth retardation, where the child appears small with slow growth rates of body parts. Despite the physical stunting, intelligence remains normal as growth hormone does not affect intellectual development. Treatment for growth hormone deficiency usually involves hormone replacement therapy to help the child achieve normal growth and development.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: Among clients with allergies, regardless of type, anaphylactic shock and angioneurotic edema are the most severe complications. Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur rapidly and affect multiple organ systems, leading to a sudden drop in blood pressure and difficulty breathing. Angioneurotic edema, also known as angioedema, is another serious allergic reaction that involves swelling of the deep layers of the skin, often around the eyes and lips, but can also affect the throat and other areas, potentially leading to airway obstruction. These complications require immediate medical attention, including the administration of epinephrine and other interventions to stabilize the client.
A 2-month-old is diagnosed with hip dysplasia. The parent asks you how long will the child be in the hip Spica Cast. How should you respond?
- A. Not longer than 4 months.
- B. The child will be placed in a Pavlik Harness for 3 to 5 months.
- C. Following the osteotomy, the child remains in a cast for 5 months.
- D. Between 2 and 4 months.
Correct Answer: B
Rationale: Hip dysplasia in infants is often managed initially with a Pavlik Harness, which helps maintain the hips in the correct position for optimum development. The Pavlik Harness is typically worn for a period of 3 to 5 months, depending on the severity of the hip dysplasia and the response to treatment. If the dysplasia is more severe or does not respond well to the Pavlik Harness, further interventions such as hip spica casting or surgery may be required, but the initial treatment is usually with the Pavlik Harness.
The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is most likely lacking in their particular diet?
- A. Fat
- B. Protein
- C. Vitamins C and A
- D. Complete protein
Correct Answer: C
Rationale: A vegetarian diet can provide adequate amounts of protein, fat, and even complete protein if well-balanced. However, certain essential nutrients like vitamins C and A are more commonly found in higher concentrations in animal-based products. Therefore, in a vegetarian diet, particularly if not carefully planned, there may be a potential lack of these specific vitamins. It is important for the nurse to educate the parents on alternative plant-based sources of vitamins C and A to ensure their child's nutritional requirements are met.
The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
- A. The newborn's length and weight are the most accurate indicators of gestational age.
- B. The newborn's Apgar score and the mother's estimated date of confinement (EDC) are combined to determine gestational age.
- C. The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age.
- D. The newborn's chest circumference compared to the head circumference is the determinant for gestational age.
Correct Answer: C
Rationale: The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age. Assessment of posture at rest involves observing the newborn's flexed or extended posture when lying flat on their back. Premature infants tend to have more flexed postures due to their immature muscular tone. Arm recoil refers to the ability of the newborn to return their extended arm flexes to the flexed position. This reflex is typically present in more mature infants. These physical signs, along with other factors such as skin texture, breast development, and ear formation, are used by healthcare providers to estimate the gestational age of newborns. While length, weight, and head circumference are also important measurements, the posture at rest and arm recoil are specifically used in determining gestational age.