Nokea
The nurse is caring for a very low birth weight (VLBW) newborn with a peripheral intravenous infusion. Which statement describes nursing considerations regarding infiltration?
- A. Infiltration occurs infrequently because VLBW newborns are inactive.
- B. Continuous infusion pumps stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. Infusion site should be checked for infiltration at least once per 8-hour shift.
Correct Answer: C
Rationale: Infiltration of intravenous fluids in VLBW newborns can lead to serious complications, especially if hypertonic solutions are being administered. Hypertonic solutions have a higher osmolarity than the body's fluids, which can cause severe tissue damage if there is infiltration. It is crucial for the nurse to monitor the infusion site closely for signs of infiltration and take prompt action to prevent further harm to the newborn's delicate skin and tissues. The other options are not directly related to the risk and consequences of infiltration in VLBW newborns.
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Which is descriptive of bulimia during adolescence?
- A. Strong sense of control over eating behavior
- B. Feelings of elation after the binge-purge cycle
- C. Profound lack of awareness that the eating pattern is abnormal
- D. Weight that can be normal, slightly above normal, or below normal
Correct Answer: C
Rationale: During adolescence, individuals with bulimia often have a profound lack of awareness that their eating pattern is abnormal. This lack of awareness can be attributed to various factors, such as societal pressures, distorted body image, and the normalization of disordered eating behaviors within their social circle. Adolescents with bulimia may not recognize their behaviors as problematic or may rationalize them as a means of coping with stress or controlling their weight. This lack of insight can make it challenging for them to seek help or receive proper treatment for their condition.
Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
- A. 1st
- B. 7th
- C. 5th
- D. 8th
Correct Answer: C
Rationale: Tic douloureux, also known as trigeminal neuralgia, is a disorder of the 5th cranial nerve. This condition is characterized by intense, sharp, stabbing, and burning pain that follows the distribution of one or more branches of the trigeminal nerve. The pain occurs in short, sudden attacks or paroxysms, typically triggered by touching specific trigger points or by activities such as eating or speaking. It is important to correctly identify and diagnose the involvement of the 5th cranial nerve in such cases to provide appropriate treatment options for the patient.
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: B
Rationale: Checking the bedside for the presence of a hypothermia blanket is crucial for providing safe care for Mrs. Zeno. Hypothermia blankets are used to prevent or treat hypothermia, which is a condition where the body temperature drops below normal levels. Maintaining normothermia (normal body temperature) is important for the overall well-being of patients, especially those who are at risk of developing complications due to temperature fluctuations. Therefore, having a hypothermia blanket readily available at the bedside ensures that the nurse can promptly address any temperature-related issues to optimize Mrs. Zeno's care and safety.
A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician prescribes mitomycin (Mutamycin) with other chemotherapeutic agents for palliative treatment. How mitomycin does exert its cytotoxic effects?
- A. It inhibits deoxyribonucleic acid (DNA) synthesis
- B. It's cell cycle-phase specific
- C. It inhibits ribonucleic acid (RNA) synthesis
- D. It inhibits protein synthesis
Correct Answer: A
Rationale: Mitomycin exerts its cytotoxic effects by forming cross-links between adjacent guanine residues in DNA, leading to inhibition of DNA synthesis. This mechanism disrupts the replication of cancer cells, ultimately inducing cell death. Mitomycin is an alkylating agent that primarily targets DNA, making it an effective treatment for certain types of cancers, such as adenocarcinoma of the stomach.
The child who walks backward, scribbles, and uses spoon and fork has achieved the developmental age of
- A. 9 mo
- B. 12 mo
- C. 15 mo
- D. 18 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 18 months of age.