Nokea
Patient S is a sexually active adolescent; which of the following instructions would be included in the preventive teaching plan about urinary tract infections?
- A. Drinking acidic juices
- B. Avoiding urinating before intercourse
- C. Wearing nylon underwear
- D. Wiping back to front
Correct Answer: A
Rationale: Drinking acidic juices, such as cranberry juice, can help make the urine more acidic, which can potentially prevent bacteria from sticking to the urinary tract walls and reduce the risk of urinary tract infections. It is important to note that while acidic juices can be beneficial in some cases, they should not be relied upon as the sole preventive measure for UTIs. Other important preventive measures include staying hydrated, practicing good hygiene, and urinating before and after intercourse.
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Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
- A. carbon dioxide level
- B. prothrombin time
- C. gastric pH
- D. white blood cell count
Correct Answer: B
Rationale: Liver cirrhosis affects the liver's ability to produce proteins that are important for blood clotting, including prothrombin. Therefore, in a patient with liver cirrhosis, Nurse Bea would expect an alteration in the prothrombin time, which measures the time it takes for the blood to clot. A prolonged prothrombin time indicates impaired blood clotting function, which is commonly seen in patients with liver disease such as cirrhosis. It is an important laboratory value to monitor in patients with liver cirrhosis to assess their risk of bleeding complications.
With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes?
- A. Hypernatremia
- B. Hyperchoremia
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: C
Rationale: Hypokalemia is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes. Potassium is an essential electrolyte for muscle function, including maintaining muscle tone and supporting proper nerve conduction for reflexes. When potassium levels are low, it can lead to muscle weakness, decreased muscle tone, and reduced deep tendon reflexes. With severe diarrhea, potassium is often lost along with fluids, leading to a potential electrolyte imbalance such as hypokalemia. Additionally, hypokalemia can cause cardiac arrhythmias, muscle cramps, and fatigue, further supporting the presence of this electrolyte imbalance in Ms. CC.
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: Option D is the most appropriate statement when assisting a patient with altered thought process and personal hygiene needs. This statement provides the patient with a choice between brushing their teeth independently or having assistance, while also emphasizing the importance of self-care activities. Offering patients choices empowers them and helps maintain their sense of autonomy, even when dealing with altered thought processes. Additionally, encouraging patients to perform activities for themselves can help improve their self-esteem and promote independence.
The primary critical observation for Apgar scoring is the:
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of the Moro reflex
Correct Answer: A
Rationale: The primary critical observation for Apgar scoring is the heart rate. This is because the heart rate is vital for life and immediate assessment of the infant's heart rate provides crucial information about the baby's overall well-being and response to the birthing process. The Apgar score assesses five components: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Among these components, the heart rate is considered the most critical because it directly reflects the infant's cardiovascular status and their ability to maintain adequate perfusion of vital organs. Therefore, for quick assessment and immediate intervention, the heart rate is prioritized as the primary observation in Apgar scoring.
Which of the following organisms is responsible for the development of rheumatic fever?
- A. Streptococcal pneumonia
- B. Haemophilus influenza
- C. Group Aß-hemolytic streptococcus
- D. Staphylococcus aureus
Correct Answer: C
Rationale: Rheumatic fever is an inflammatory disease that can develop after an untreated or inadequately treated infection with group Aß-hemolytic streptococcus bacteria, particularly Streptococcus pyogenes. This bacteria causes strep throat, which if left untreated, can lead to complications such as rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain. It is important to promptly treat streptococcal infections with antibiotics to prevent the development of rheumatic fever.