Nokea
The MOST common type of cerebral palsy is
- A. ataxic cerebral palsy
- B. spastic cerebral palsy
- C. dystonic cerebral palsy
- D. dyskinetic cerebral palsy
Correct Answer: B
Rationale: Spastic cerebral palsy is the most common type.
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A client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis site for cancer cells?
- A. Liver
- B. Reproductive tract
- C. Colon
- D. White blood cells (WBCs)
Correct Answer: A
Rationale: The liver is one of the most common sites for metastasis of cancer cells. This is because the liver receives a high volume of blood flow, making it a common site for cancer cells to spread through the bloodstream. Additionally, the liver's function in filtering toxins and foreign substances from the blood makes it a favorable environment for cancer cells to establish secondary tumors. Monitoring the liver for metastasis is crucial in cancer diagnosis and management.
The age at which the infant can achieve early head control with bobbing motion when pulled to sit is
- A. 2 months
- B. 3 months
- C. 4 months
- D. 6 months
Correct Answer: A
Rationale: Head control typically begins developing around 2 months.
Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave's disease?
- A. keep an accurate record of intake and output.
- B. use nasal desmopressin acetate (DDAVP).
- C. be sure to get regular follow-up care.
- D. Be sure to exercise to improve cardiovascular fitness.
Correct Answer: C
Rationale: Regular follow-up care is crucial after a thyroidectomy for Grave's disease to monitor the patient's thyroid hormone levels, assess for signs of complications such as hypothyroidism or hypoparathyroidism, and ensure appropriate management of any related conditions. Routine follow-up visits with healthcare providers allow for ongoing assessment and adjustment of medications, as well as addressing any concerns the patient may have post-surgery. By emphasizing the importance of regular follow-up care, the healthcare team can provide necessary support and guidance to the patient throughout their recovery process.
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.
A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours after birth, the newborn begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. Which is important for the nurse to recognize?
- A. This is a normal finding.
- B. This is not significant unless cyanosis is present.
- C. Improvement should occur within 24 hours.
- D. Further evaluation is needed.
Correct Answer: D
Rationale: The presentation of a preterm newborn with difficulty breathing, grunting, tachypnea, and nasal flaring is concerning and should not be considered a normal finding. This could indicate respiratory distress, which is common in preterm infants due to immature lung development. It is important for the nurse to recognize these symptoms as they may signify a potential underlying respiratory issue that requires further evaluation and intervention. Prompt assessment and management are crucial in ensuring the best outcomes for the newborn. Therefore, further evaluation by the healthcare team is warranted in this situation to determine the cause of the respiratory distress and provide appropriate treatment.