Nokea
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.
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Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When the WBC count rises to
- C. When lost hair begins to grow back 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The correct answer is A because the drug should be resumed when the WBC count falls to 5,000mm3 to ensure the client's safety and efficacy of treatment. This criterion indicates that the client's immune system has recovered sufficiently to tolerate the drug. Choices B, C, and D are incorrect because they do not directly correlate with the client's immune system recovery, which is crucial for drug tolerance. Choice B focuses on the rise in WBC count, not the fall to a specific level. Choice C is related to a cosmetic side effect, not clinical readiness. Choice D is unrelated to immune system recovery.
Which of the ff. subjective data questions would assist the nurse in assessing the patient’s eye health?
- A. “Have you had any recent upper respiratory infections?”
- B. “Have you ridden in a car recently?”
- C. “Have you been scuba diving lately?”
- D. “Have you seen halos around lights?”
Correct Answer: D
Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: A
Rationale: The correct answer is A because decorticate posturing is characterized by flexion of both upper and lower extremities. This occurs due to damage to the cerebral hemispheres, resulting in abnormal muscle contractions. Choice B describes decerebrate posturing, which is associated with extension of elbows and knees. Choice C is incorrect as it describes abnormal posturing seen in other conditions. Choice D is also incorrect as it describes a different type of abnormal posturing.
For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?
- A. Teaching coughing and deep-breathing techniques to help prevent infection
- B. Administering platelets, as ordered to maintain an adequate platelet count
- C. Giving aspirin, as prescribed to control body temperature
- D. Administering stool softeners, as ordered, to prevent straining during infection
Correct Answer: B
Rationale: The correct answer is B: Administering platelets, as ordered to maintain an adequate platelet count. In ITP, the client has low platelet count leading to risk of bleeding. Administering platelets helps raise platelet levels and prevent bleeding complications. Teaching coughing and deep-breathing techniques (A) is important for preventing respiratory infections but not directly related to ITP. Giving aspirin (C) is contraindicated as it can further decrease platelet count. Administering stool softeners (D) is important for preventing straining but not specific to managing ITP.
Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?
- A. acute viral hepatitis
- B. alcohol hepatotoxicity
- C. chronic biliary inflammation or obstruction
- D. hepatic failure with prolonged venous hepatic congestion
Correct Answer: C
Rationale: The correct answer is C: chronic biliary inflammation or obstruction. Biliary cirrhosis is a condition characterized by scarring of the liver due to long-term damage to the bile ducts. Chronic biliary inflammation or obstruction can lead to the build-up of bile in the liver, causing damage over time. Acute viral hepatitis (choice A) typically does not directly cause biliary cirrhosis. Alcohol hepatotoxicity (choice B) is more commonly associated with alcoholic liver disease rather than biliary cirrhosis. Hepatic failure with prolonged venous hepatic congestion (choice D) may lead to liver cirrhosis, but it is not specific to biliary cirrhosis.