Nokea
Nutritional considerations as part of the nursing care plan would include all of the following except that:
- A. The diet should be semisolid to facilitate the passage of food f. Calcium should be avoided g. The patient should be sitting in an upright position during feeding h. Thick fluids should be encouraged to provide additional calories NEUROLOGIC Situation - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
Correct Answer: B
Rationale: It is important to consider calcium supplementation for patients with spinal cord injuries, especially those with paraplegia, as they are at an increased risk of developing osteoporosis due to decreased weight-bearing activities. Calcium is necessary for bone health and should not be avoided in the diet of patients with spinal cord injuries. Therefore, the statement "Calcium should be avoided" is incorrect in this context as it goes against the nutritional considerations that should be included in the nursing care plan for a patient like Richard Gabatan.
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Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
- A. A sunken fontanel
- B. Decreased pulse rate
- C. Increased blood pressure
- D. Low urine specific gravity
Correct Answer: A
Rationale: A sunken fontanel is a classic sign of dehydration in infants. When a child is experiencing fluid volume deficit, the body's priority is to maintain blood flow to vital organs, resulting in decreased blood circulation to the skin and extremities. Consequently, decreased skin turgor and a sunken fontanel are common manifestations of dehydration. Other signs of fluid volume deficit may include dry mucous membranes, lethargy, decreased urine output, and increased heart rate.
A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is "term" if which findings are assessed? (Select all that apply.)
- A. Posture with fully flexed arms and legs
- B. Arm recoil brisk
- C. Square window at 90 degrees
- D. Scarf sign of elbow crossing over the midline
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.
Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response? a.All the girls will be normal and the other son a carrier
- A. All the girls will be carriers and one half the boys will be affected
- B. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
- C. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.