Nokea
A woman in active labor is experiencing prolonged rupture of membranes (>24 hours). What complication should the nurse assess for in the mother and fetus?
- A. Intrauterine infection
- B. Fetal macrosomia
- C. Placental abruption
- D. Maternal hypotension
Correct Answer: A
Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.
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Which of the following is NOT TRUE of type 2 diabetes Mellitus?
- A. Increased production of glucose from the liver
- B. Insulin resistance in the peripheral tissues
- C. Destruction of beta cell from autoimmune mechanism which result in lack of insulin and hyperglycemia
- D. Defective beta cell secretion with loss of insulin
Correct Answer: C
Rationale: Type 2 diabetes mellitus is characterized by insulin resistance in the peripheral tissues and defective beta cell secretion with loss of insulin. In type 2 diabetes, there is typically not destruction of beta cells from an autoimmune mechanism that leads to lack of insulin and hyperglycemia as seen in type 1 diabetes mellitus. Instead, in type 2 diabetes, the pancreas initially produces insulin, but the body's cells become resistant to its effects. This results in hyperglycemia due to the inability of the body to properly regulate blood sugar levels. Therefore, choice C is not true for type 2 diabetes mellitus.
The 5's strategy to prevent dengue infection includes the following, EXCEPT
- A. Search and Destroy mosquito breeding places
- B. Apply mosquito repellent all over your body
- C. seek early consultation at the neatest health care facility
- D. Say no to fogging spraying, and misting in hot spot areas
Correct Answer: B
Rationale: The 5's strategy to prevent dengue infection includes Search and Destroy mosquito breeding places, seek early consultation at the nearest health care facility, say no to fogging spraying, and misting in hot spot areas. While using mosquito repellent on exposed skin is a common preventive measure against mosquito bites, applying it all over your body is not included in the official 5's strategy for dengue prevention. The focus of the 5's strategy is on eliminating mosquito breeding sites, seeking medical advice early in case of symptoms, and avoiding certain mosquito control methods like fogging in hot spot areas.
A patient presents with muscle weakness, fatigue, constipation, and hyperpigmentation of the skin. Laboratory tests reveal low serum cortisol levels and elevated adrenocorticotropic hormone (ACTH) levels. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Addison's disease
Correct Answer: D
Rationale: The symptoms described - muscle weakness, fatigue, constipation, hyperpigmentation of the skin, low serum cortisol levels, and elevated ACTH levels - are classic findings in Addison's disease. Addison's disease is a primary adrenal insufficiency characterized by the insufficient production of cortisol and, to some extent, aldosterone. The low cortisol levels result in symptoms such as muscle weakness, fatigue, and skin hyperpigmentation due to increased levels of ACTH stimulating melanin production. In contrast, in conditions like hyperthyroidism, hypothyroidism, and diabetes mellitus, the symptoms and laboratory findings would not fully align with those described in the patient in this scenario.
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
- A. Risk for denial
- B. Ineffective tissue perfusion
- C. Impaired gas exchange
- D. Acute pain
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
Which information about the nature of dengue fever the nurse should relay to the community?
- A. It is always life threatening
- B. It could be deadly but preventable
- C. It could responds well to antibiotics
- D. The incubation period is variable
Correct Answer: B
Rationale: The correct information about the nature of dengue fever that the nurse should relay to the community is that it could be deadly but preventable. Dengue fever is a viral infection spread by mosquitoes, particularly the Aedes aegypti mosquito. While many cases of dengue fever are mild, it can also lead to severe dengue, which can be life-threatening if not properly managed. However, preventive measures such as using mosquito repellent, wearing protective clothing, and eliminating breeding sites for mosquitoes can significantly reduce the risk of contracting dengue fever. Therefore, it is important for the community to be aware that while dengue fever can be deadly, it is also preventable with appropriate measures.