Nokea
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: Turning the patient frequently every 2 hours helps relieve pressure on specific areas of the body, hence reducing the risk of developing decubitus ulcers. Prolonged pressure on the skin can lead to poor blood circulation and tissue damage, which can eventually progress into decubitus ulcers. By turning the patient regularly, the pressure is redistributed and different areas of the skin are relieved from constant stress. This simple measure is an effective way to prevent the occurrence of decubitus ulcers in patients on prolonged bed rest.
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The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
- A. Renal calculi
- B. Delayed ejaculation
- C. Hematuria
- D. Impotence
Correct Answer: C
Rationale: Bacillus Calmette-Guerin (BCG) is a form of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells in the bladder. One of the common side effects of BCG therapy is hematuria, which is the presence of blood in the urine. This can be expected due to the irritation caused by the BCG instillations in the bladder lining. Hematuria is usually mild to moderate and can resolve on its own without specific treatment.
Biopsy is not usually performed for a child with suspicion of Wilms tumor EXCEPT
- A. age of 2-3 year
- B. signs of inflammation or infection
- C. significant lymph node enlargement radiologically
- D. intratumoral calcification radiologically
Correct Answer: D
Rationale: Presence of intratumoral calcifications may warrant biopsy to rule out other diagnoses.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis (ALS) are all affected by various neuromuscular conditions that can lead to respiratory complications. These conditions can cause weakness in the muscles involved in breathing, leading to difficulties with coughing, clearing secretions, and maintaining adequate ventilation. This weakness can ultimately result in an increased risk of breathing difficulties, respiratory infections, and respiratory failure. Therefore, clients with these conditions require close monitoring and respiratory support to manage and prevent complications related to respiratory function.
The least common late neurologic sequelae that may be encountered post craniospinal irradiation in a 9-year-old child with medulloblastoma is
- A. microcephaly
- B. learning disabilities
- C. cognitive impairment
- D. second malignancy
Correct Answer: D
Rationale: Second malignancy is a rare late effect compared to cognitive and learning impairments.
Which patient would benefit most from a capped IV catheter that is used intermittently rather than continuously?
- A. The patient with pneumonia who needs fluids and antibiotics.
- B. The patient who has had major blood loss after a motor vehicle accident.
- C. The young child who is dehydrated.
- D. The elderly patient who is receiving a diuretic for fluid overload.
Correct Answer: D
Rationale: The elderly patient who is receiving a diuretic for fluid overload would benefit most from a capped IV catheter used intermittently rather than continuously. Diuretics cause the body to expel excess fluid, so the patient may require intermittent IV fluid replacement to maintain hydration while avoiding overloading the system with excessive fluids. By using the IV catheter intermittently, healthcare providers can closely monitor the patient's fluid status and adjust fluid administration as needed to prevent dehydration or fluid overload. This approach allows for more precise management of the patient's fluid balance compared to continuous IV infusion.