Nokea
The nurse is aware that which occurrence in the patient 's health history suggests the diagnosis of GBS?
- A. viral illness few weeks before
- B. encephalitis
- C. severe bacterial infection
- D. meningitis
Correct Answer: A
Rationale: The correct answer is A because a viral illness few weeks before can trigger Guillain-Barre Syndrome (GBS) due to the body's immune response attacking the peripheral nerves. Encephalitis (B), severe bacterial infection (C), and meningitis (D) are not directly linked to GBS pathophysiology. Viral infections are known to precede GBS development, making choice A the most appropriate option.
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The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?
- A. Symphysis pubis
- B. Midline
- C. Umbilicus
- D. Sides of the abdomen
Correct Answer: C
Rationale: The correct answer is C: Umbilicus. The nurse begins assessing the uterine fundus at the level of the umbilicus as it is a standard reference point for postpartum fundal height measurement. This location allows for consistency and accuracy in tracking the descent of the uterus back into the pelvic cavity. Starting at the umbilicus also helps in monitoring the involution process and prevents potential errors in fundal height assessment.
Symphysis pubis (A) is too low and not typically used as a reference point for uterine fundal assessment. Midline (B) is vague and does not provide a specific anatomical landmark. Sides of the abdomen (D) do not give a standardized starting point for measuring the uterine fundus, leading to potential variability in assessment.
A woman in active labor is receiving an epidural analgesic for pain relief. What assessment findings indicate a potential complication of epidural analgesia?
- A. Maternal hypotension
- B. Uterine hyperstimulation
- C. Fetal tachycardia
- D. Respiratory depression
Correct Answer: A
Rationale: One potential complication of epidural analgesia in labor is maternal hypotension. The epidural analgesic can cause vasodilation, leading to a decrease in blood pressure. Maternal hypotension can result in decreased placental perfusion, which may jeopardize fetal well-being. It is important for healthcare providers to monitor the maternal blood pressure closely and intervene promptly if hypotension occurs by providing IV fluids or administering medication to raise blood pressure. Uterine hyperstimulation, fetal tachycardia, and respiratory depression are not typically associated with epidural analgesia as complications.
Nurse Pedrito is teaching a client with Parkinson's disease on ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to _________.
- A. Rest in supine position with his head elevated.
- B. Sleep only in dorsal recumbent position.
- C. Periodically lie in prone position without a neck pillow.
- D. Sleep on either side, but keep his back straight.
Correct Answer: C
Rationale: The correct answer is C: Periodically lie in prone position without a neck pillow. This position helps to prevent spinal flexion by promoting extension of the spine and stretching of the hip flexors. Prone positioning also helps maintain alignment of the spine and prevents contractures. Resting in supine position (choice A) with the head elevated does not promote spinal extension. Sleeping only in dorsal recumbent position (choice B) may lead to spinal flexion. Sleeping on either side (choice D) does not specifically address spinal flexion prevention.
A patient with chronic bronchitis presents with chronic cough, sputum production, and exertional dyspnea. Which of the following interventions is most appropriate for managing the patient's symptoms and improving quality of life?
- A. Smoking cessation counseling
- B. Oral antibiotic therapy
- C. Home oxygen therapy
- D. Bronchodilator therapy
Correct Answer: D
Rationale: The correct answer is D: Bronchodilator therapy. Bronchodilators help to relax and open up the airways, which can improve airflow and reduce symptoms such as cough, sputum production, and dyspnea in patients with chronic bronchitis. This intervention can help manage the patient's symptoms and improve their quality of life by making it easier for them to breathe.
A: Smoking cessation counseling is important for overall management of chronic bronchitis, but it does not directly address the patient's current symptoms.
B: Oral antibiotic therapy may be indicated if there is evidence of a bacterial infection, but it is not the first-line treatment for managing chronic bronchitis symptoms.
C: Home oxygen therapy may be necessary for patients with severe hypoxemia, but it is not typically the first intervention for managing symptoms of chronic bronchitis without evidence of significant oxygen desaturation.
To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.
- A. tilt head to side if sitting up.
- B. Lie on the affected area
- C. put the pillows behind the head
- D. lie on the non-affected ear.
Correct Answer: B
Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.