Nokea
Nurse Lorna is assessing infantile reflexes in a 9-month-old baby; which of the following would she identify as normal?
- A. Persistent rooting
- B. Bilateral parachute
- C. Absent moro reflex
- D. Unilateral grasp
Correct Answer: B
Rationale: The parachute reflex typically emerges around 9 months of age and is considered a normal reflex in infants. This reflex is characterized by the infant extending their arms to protect themselves when they feel like they are falling. This is an important protective reflex that helps a child develop their sense of balance and coordination. Persistent rooting is not a normal reflex in a 9-month-old baby, as it typically disappears by 4 months of age. The Moro reflex is typically present in infants and involves an outstretched movement of the arms when startled, so its absence would not be considered normal at this age. A unilateral grasp is also not a normal reflex at 9 months, as infants should be able to show coordinated bilateral movements by this age.
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After surgery the nurse notes that the patient's urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
- A. The sympathetic nervous system saves fluid in response to stress of surgery.
- B. The sympathetic nervous system diereses fluid in response to stress of surgery.
- C. The parasympathetic nervous system saves fluid in response to stress of surgery.
- D. The parasympathetic nervous system diereses fluid in response to stress of surgery.
Correct Answer: A
Rationale: The sympathetic nervous system saves fluid in response to the stress of surgery, leading to the urine becoming dark amber and concentrated. During stressful events such as surgery, the body activates the sympathetic nervous system as part of the fight-or-flight response. One of the functions of the sympathetic nervous system in this situation is to conserve fluids in the body by reducing urine output. This results in more concentrated urine, often appearing dark amber in color. Conversely, the parasympathetic nervous system is not typically involved in conserving fluid during stress responses.
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
- A. Administer oxygen therapy
- B. provide frequent linen changes
- C. provide fluid intake 3L/day
- D. maintain complete bed rest
Correct Answer: A
Rationale: Administering oxygen therapy would be the priority intervention in this case because Arthur is experiencing pneumonia with a high fever (39° to 40° C). High fever can lead to increased oxygen demand in the body, and providing supplemental oxygen can help ensure that Arthur is receiving adequate oxygenation to support his respiratory function. Oxygen therapy can also help improve oxygen saturation levels, which may be compromised due to the pneumonia. Therefore, addressing the potential respiratory distress caused by the pneumonia and fever should be the top priority to optimize Arthur's oxygenation levels and respiratory function.
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.
A 6-year-old male child presented with a cerebellar mass; after undergoing complete surgical resection of the mass, the histology of the mass reveals pilocytic astrocytoma. Of the following, the MOST appropriate next step in the management is
- A. radiotherapy
- B. chemotherapy
- C. observation
- D. concomitant chemo-radiotherapy
Correct Answer: C
Rationale: Pilocytic astrocytomas are generally low-grade tumors, and observation is often sufficient after complete resection.
When planning the education for the parents of a child with type 1 diabetes mellitus, which of the following should the nurse include?
- A. Restrict the activity of the child
- B. Rotate insulin injection sites
- C. Avoid letting the child perform the home testing of blood sugar
- D. Encourage a high-carbohydrate diet
Correct Answer: B
Rationale: When planning education for the parents of a child with type 1 diabetes mellitus, the nurse should include rotating insulin injection sites. This is important to prevent lipohypertrophy, which is the buildup of fat under the skin, and to ensure consistent absorption of insulin. Rotating injection sites helps to maintain healthy tissue and promotes better insulin effectiveness in managing blood sugar levels. It is a key component of proper diabetes care and helps to reduce the risk of complications associated with continuous injection in the same area.