Nokea
The mother of a 9-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy. The nurse should:
- A. Explain that he does not need the added stimulation
- B. Allow the player, but ask him to wear earphones
- C. Tell the mother that he cannot have items from home
- D. Ask the mother to bring a battery-operated CD instead
Correct Answer: B
Rationale: Allowing the CD player with earphones provides comfort without disturbing others or interfering with oxygen therapy.
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A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
- A. I keep having recurring nightmares.
- B. I have a headache and my vision is blurry.
- C. I feel like I'm watching myself from outside my body.
- D. I hear voices telling me what to do.
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
The nurse reviews a 21-year-old female's bloodwork from the lab. Which result would be charted as an abnormal finding?
- A. platelets 129
- B. RBC 4.2
- C. WBC 15.6
- D. hematocrit 38%
Correct Answer: C
Rationale: WBC 15.6 (normal 4.5-11.0 x 10³/μL) is elevated, indicating possible infection or inflammation. Platelets (150-450 x 10³/μL) are slightly low, RBC (4.2-5.4 million/μL) and hematocrit (36-46%) are normal for females.
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
- A. Uncompensated respiratory acidosis
- B. Uncompensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
Which finding is associated with Tay Sachs disease?
- A. Pallor of the conjunctiva
- B. Cherry-red spots on the macula
- C. Blue-tinged sclera
- D. White flecks in the iris
Correct Answer: B
Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.
Which of the following are common neurological changes associated with aging? Select all that apply.
- A. Dementia occurs.
- B. Threshold for sensory input increases.
- C. Perspiration is reduced.
- D. Short-term memory is impaired.
- E. Muscles atrophy.
Correct Answer: B,D
Rationale: Aging commonly increases sensory input threshold (B), making stimuli harder to perceive, and impairs short-term memory (D). Dementia (A) is not universal, perspiration reduction (C) is not neurological, and muscle atrophy (E) is musculoskeletal.