Nokea
The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?
- A. uneven head shape
- B. respirations are irregular, abdominal, 30-60 bpm
- C. (+) Moro reflex
- D. heart rate is 80 bpm
Correct Answer: D
Rationale: The heart rate of a normal newborn is typically 120 to 160 bpm. Therefore, a heart rate of 80 bpm would be least likely to be observed in a normal newborn. This finding may indicate bradycardia, which should be further evaluated and managed by the healthcare provider. Other options such as an uneven head shape, irregular respirations, (+) Moro reflex are common and expected in newborns.
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What orders would likely be included fro a client diagnosed with multiple myeloma?
- A. Bed rest
- B. Fluid restriction
- C. Corticosteroid therapy
- D. Calcium replacement therapy
Correct Answer: C
Rationale: Corticosteroid therapy is commonly used in the treatment of multiple myeloma. It is often part of the initial treatment plan for this disease and is used to help control the cancer cells by reducing inflammation and immune responses. Corticosteroids can help manage symptoms such as pain and complications related to the disease. Bed rest, fluid restriction, and calcium replacement therapy may not be directly indicated for multiple myeloma treatment.
Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:
- A. nothing because these are normal findings
- B. the nurse should conduct a thorough nutritional assessment
- C. understanding that the client should be advised to have the test repeated in three months
- D. understanding that anemia is a part of the degeneration of the bone marrow
Correct Answer: B
Rationale: Aling Iska's hemoglobin level of 11mg/dl and hematocrit level of 32% are both below the normal range for her age group. These low levels indicate anemia, which is a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can be caused by various factors, such as nutritional deficiencies (iron, vitamin B12, folate), chronic diseases, or bone marrow problems. In this case, given Aling Iska's advanced age of 78 years, it is essential for the nurse to conduct a thorough nutritional assessment to determine if her anemia is related to any deficiencies that can be addressed through dietary changes or supplementation. It is important to identify the underlying cause of anemia to provide appropriate interventions and prevent further complications.
Almost all of the diseases detected in neonatal screening programs have a very low prevalence; the strategy is to use the initial screening test to separate a highly suspect group from normal and then follow this suspect group aggressively. Of the following, the disease that has low prevalence rendering it not useful for neonatal screening testing is
- A. phenylketonuria
- B. hypothyroidism
- C. cystic fibrosis
- D. neuroblastoma
Correct Answer: D
Rationale: Neuroblastoma has a very low prevalence and is not typically screened for in neonatal programs due to its rarity and the inefficiency of mass screening for such a condition.
Wilma knew that James have an adequate respiratory condition if she notices that
- A. James' respiratory rate is 18
- B. James' Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: An adequate respiratory condition can be indicated by a normal respiratory rate. The normal adult respiratory rate typically ranges from 12 to 20 breaths per minute. In this case, if James' respiratory rate is 18, it falls within the normal range and would suggest that his respiratory condition is adequate. Oxygen saturation levels and the presence of blood suction or secretions are important factors to consider as well, but directly assessing the respiratory rate provides a more immediate indication of respiratory status.
Minda, a 65-year old female has been admitted with a left hemisphere stroke. Which behavioral change would the nurse expect to find upon assessment?
- A. impulsive, unsafe activity
- B. motor deficits on the right eye
- C. motor deficits on the left side of the body
- D. error in word choices
Correct Answer: D
Rationale: A left hemisphere stroke typically affects the right side of the body due to the way the brain controls motor functions. Since the left hemisphere is also responsible for language and speech processing, patients with a left hemisphere stroke commonly exhibit errors in word choices, difficulty speaking or understanding language, aphasia, and other language-related impairments. This is known as Broca's aphasia or expressive aphasia. Therefore, the nurse would expect to find errors in word choices as a behavioral change in a patient like Minda with a left hemisphere stroke.