Nokea
The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy. Which is an appropriate nursing intervention for this newborn?
- A. Apply lotion as prescribed to moisturize skin.
- B. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting.
- C. Monitor temperature to prevent hypothermia or hyperthermia.
- D. Keep eye patches on for at least 8 to 12 of every 24 hours.
Correct Answer: C
Rationale: Monitoring temperature to prevent hypothermia or hyperthermia is an appropriate nursing intervention for a newborn with hyperbilirubinemia receiving phototherapy. Phototherapy can increase the risk of hypothermia in newborns due to increased heat loss from evaporation, convection, and conduction. On the other hand, hyperthermia can occur if the newborn is over-wrapped or placed too closely to the light source. Therefore, frequent temperature monitoring is essential to maintain a stable body temperature within a normal range and prevent adverse effects related to temperature dysregulation.
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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.
Scoliosis That Greater 40 Degree Curvature Is Usually Treated By :
- A. Exercise
- B. Spinal fusion surgery
- C. Bracing
- D. Casting
Correct Answer: B
Rationale: When scoliosis progresses to a greater than 40-degree curvature, it is often treated with spinal fusion surgery. This surgical procedure involves fusing together the vertebrae in the curved part of the spine to correct the curvature. Spinal fusion surgery is typically recommended for severe cases of scoliosis to halt the progression of the curve and prevent further complications such as lung and heart problems. Other treatment options like exercise, bracing, and casting may be more suitable for milder cases or as a preventative measure in certain situations.
You are explaining the risk of leukemia in children with Down syndrome to medical students; your discussion will include all the following statements EXCEPT
- A. acute leukemia occurs more frequently in children with Down syndrome than in the general population
- B. AML is more common in children with Down syndrome as compared to ALL
- C. children with Down syndrome have a slightly inferior outcome ratio of ALL/AML in general
- D. children with Down syndrome who develop AML demonstrate remarkable sensitivity to antimetabolites
Correct Answer: D
Rationale: Children with Down syndrome often have better outcomes when treated with specific regimens, contrary to this option.
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.
All the following are true about infant sleep between 2-6 months EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles differ significantly from adult patterns.