Nokea
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.
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What are the nursing interventions for a client with thalassemia?
- A. Maintain the client on bed rest and protect him or her from infections
- B. Ambulate the client frequently
- C. Advise drinking 3 quarts (L) of fluid per day
- D. Instruct the client to elevate the lower extremities as much as possible
Correct Answer: A
Rationale: Thalassemia is a genetic blood disorder that results in the reduced production of hemoglobin and red blood cells. Nursing interventions for a client with thalassemia aim to manage symptoms and prevent complications. Maintaining the client on bed rest helps conserve energy and prevent fatigue, which is commonly experienced due to anemia. Protecting the client from infections is crucial because individuals with thalassemia are at a higher risk of infections due to their weakened immune system. By minimizing the risk of infections, nurses can help prevent further complications in clients with thalassemia.
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: Clients with immune system disorders may receive treatments such as immunoglobulin therapy or biologic agents through infusions. It is essential for the nurse to monitor the client for infusion reactions, which can include symptoms such as fever, chills, nausea, and allergic reactions. Early recognition of infusion reactions is crucial for prompt intervention to prevent complications and ensure the client's safety. By closely monitoring the client during and after the infusion, the nurse can detect and address any adverse reactions promptly.
The nurse is caring for a newborn who was born 24 hours ago to a mother who received no prenatal care. The newborn is a poor feeder but sucks avidly on his hands. Clinical manifestations also include loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating. Which should the nurse suspect?
- A. Seizure disorder
- B. Narcotic withdrawal
- C. Placental insufficiency
- D. Meconium aspiration syndrome
Correct Answer: B
Rationale: The clinical manifestations described in the scenario are classic signs of neonatal abstinence syndrome (NAS), which occurs in newborns who were exposed to drugs, particularly narcotics, in utero. The newborn's symptoms of poor feeding, sucking on his hands, tachycardia, fever, projectile vomiting, loose stools, sneezing, and generalized sweating are consistent with NAS. These symptoms occur as the newborn experiences withdrawal from the drugs to which they were exposed during pregnancy. In this case, the lack of prenatal care suggests that the mother may have used narcotics during pregnancy, leading to NAS in the newborn. It is essential for healthcare providers to recognize these signs and provide appropriate care and support for infants experiencing NAS.
The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
- A. "Be sure to take glipizide 30 minutes before meals."
- B. "Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly."
- C. "You won't need to check you blood glucose level after you start taking glipizide."
- D. "Take glipizide after a metal to prevent heartburn."
Correct Answer: A
Rationale: A. "Be sure to take glipizide 30 minutes before meals."
The nurse is caring for a patient, age 68, who is receiving digoxin (Lanoxin) 0.125 mg qd for cardiac myopathy. Which of the following assessments of the patient would indicate that he is experiencing a side effect of digoxin that requires follow-up?
- A. Skin flushing c.Hypertension
- B. Anorexia
- C. Constipation
Correct Answer: B
Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.