Nokea
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature g. Allow him to wear his own clothing f. Encourage to perform his own personal h. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.
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Common side effects of stimulant medications include
- A. appetite suppression
- B. gastrointestinal tract symptoms
- C. sedation
- D. hepatitis
Correct Answer: A
Rationale: Appetite suppression is a common side effect of stimulant medications used to treat ADHD.
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: D
Rationale: Administering edrophonium (Tensilon) to a client with myasthenia gravis helps differentiate between cholinergic crisis and myasthenic crisis. In cholinergic crisis, which is caused by excessive acetylcholine levels due to an overdose of anticholinesterase medications, the client may experience a temporary worsening of symptoms such as muscle weakness, respiratory distress, and other cholinergic effects. This temporary worsening is due to the increase in acetylcholine levels, leading to overstimulation of nicotinic and muscarinic receptors. On the other hand, in myasthenic crisis, which is caused by insufficient acetylcholine at the neuromuscular junction, administering edrophonium would lead to an improvement in muscle weakness. Therefore, if the client experiences a temporary worsening of symptoms after receiving edrophonium, it indicates cholinergic crisis.
What is the single most important factor to consider when communicating with children?
- A. The child's physical condition
- B. Presence or absence of the child's parent
- C. The child's developmental level
- D. The child's nonverbal behaviors
Correct Answer: C
Rationale: The single most important factor to consider when communicating with children is the child's developmental level. Understanding where a child is at in terms of cognitive, emotional, and social development is crucial for effective communication. By considering the child's developmental level, you can adjust your language, tone, and content to suit their abilities and needs. This ensures that the child can understand and engage with the communication effectively. Communication that aligns with a child's developmental stage promotes better comprehension, engagement, and relationship-building.
The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
- A. Meconium
- B. Transitional
- C. Miliaria
- D. Milk stool
Correct Answer: A
Rationale: Meconium is the term used to describe the first stool of a newborn. This stool is black and tarry in appearance. Meconium is made up of materials ingested by the fetus while in the uterus, such as mucus, amniotic fluid, and cells shed from the stomach and intestines. It is typically passed by a newborn within the first few days of life before transitioning to transitional stools, which are greenish-brown in color, and eventually to normal milk stools as the baby starts feeding on breast milk or formula.
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
- A. Prevent strenuous exercises by the client
- B. Use pressure relieving devices when the client is in bed
- C. Place the client in Fowler's position
- D. Avoid giving daily baths with soaps to the client
Correct Answer: B
Rationale: Using pressure relieving devices when the client is in bed is essential to prevent skin breakdown. Clients with neuromuscular disorders are at higher risk for impaired skin integrity due to limited mobility and sensation. Pressure relieving devices such as specialized mattresses, cushions, or pads help distribute pressure evenly and reduce the risk of pressure ulcers. Maintaining good skin integrity is crucial in preventing complications and promoting the overall well-being of the client. It is important for the nurse to assess the client's risk factors, implement preventive measures like using pressure relieving devices, and monitor the client's skin regularly to prevent skin breakdown.