Nokea
The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching?
- A. "He should increase his fluid intake regularly to thin secretions."
- B. "We'll make sure that he avoids exercise to prevent attacks."
- C. "He is to use his bronchodilator inhaler before the steroid inhaler."
- D. "We need to identify what things trigger his attacks." 50
Correct Answer: B
Rationale: It is important to note that exercise should not be completely avoided for a child with asthma. Regular physical activity is beneficial for overall health and can help improve lung function in asthmatic individuals. Supervised and controlled exercise under the guidance of healthcare providers can be safe for children with asthma. Avoiding exercise altogether can lead to deconditioning and other health issues. It is important to educate the family on the proper management of asthma during exercise, such as using a rescue inhaler before engaging in physical activity. Therefore, this statement indicates a need for further home care teaching.
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A surgical intervention that can cause substantial remission of myasthenia gravis is:
- A. Esophagostomy
- B. Thymectomy
- C. Myomectomy
- D. Spleenectomy
Correct Answer: B
Rationale: Thymectomy is a surgical procedure that involves the removal of the thymus gland. The thymus is a key component of the immune system and is believed to play a role in the development of myasthenia gravis (MG). In some cases, particularly in younger patients with early onset MG or with thymoma (a tumor of the thymus), thymectomy can lead to substantial remission of MG symptoms or even a cure. By removing the thymus gland, the abnormal immune response in MG may be reduced, resulting in improved muscle strength and decreased symptoms. It is worth noting that thymectomy is not always indicated for all patients with MG and should be considered on a case-by-case basis in consultation with a healthcare provider specialized in neuromuscular diseases.
The most common type of CP is :
- A. Athetoid
- B. B.Spastic
- C. Ataxic
- D. None Of The Above
Correct Answer: B
Rationale: Spastic cerebral palsy is the most common type of cerebral palsy, accounting for around 70-80% of cases. Spastic CP is characterized by stiff, tight muscles that can affect movement and coordination. This type of CP is caused by damage to the motor cortex of the brain, leading to increased muscle tone and difficulty with voluntary movements. Symptoms of spastic CP can vary in severity and may affect one or multiple limbs.
A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
- A. Nystagmus
- B. Profuse drooling
- C. Dark green or black stools
- D. Slight vaginal reddish discharge
Correct Answer: A
Rationale: Nystagmus refers to involuntary and repetitive eye movements. It is considered abnormal in a newborn as it may be a sign of a neurological or visual problem. Therefore, if a nurse observes nystagmus during a newborn assessment, it should be further investigated and discussed with a healthcare provider to determine the underlying cause and appropriate management. Profuse drooling, dark green or black stools, and slight vaginal reddish discharge are common findings in newborns and do not typically indicate a serious health issue.
Stefan was diagnosed with secondary vesicoureteral reflux; such condition usually results from which of the following?
- A. Acidic urine
- B. Congenital defects
- C. Hydronephrosis
- D. Infection
Correct Answer: D
Rationale: Secondary vesicoureteral reflux is a condition where urine flows backward from the bladder into the ureters and possibly towards the kidneys due to an underlying cause. In the majority of cases, it results from an infection in the urinary tract, particularly in the bladder. The infection leads to inflammation and weakening of the valves that normally prevent urine from refluxing back towards the kidneys. This condition is more common in children but can also occur in adults. Treating the underlying infection is essential to managing secondary vesicoureteral reflux and preventing complications such as kidney damage.
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
- A. Raise the client's head
- B. Place the client on a firm mattress
- C. Call the physician
- D. Administer an analgesic to relieve the pain
Correct Answer: C
Rationale: The sudden severe headache and nasal congestion in a client with a spinal cord injury at the level of T3, along with flushed skin, goose bumps, and potentially increased blood pressure due to autonomic dysreflexia. This is a medical emergency that requires immediate intervention from a healthcare provider. Calling the physician ensures prompt assessment and treatment to prevent further complications associated with autonomic dysreflexia, such as hypertensive crisis, seizures, or stroke. It is important to address this situation promptly to prevent any serious consequences for the client's health.