Nokea
The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is most likely lacking in their particular diet?
- A. Fat
- B. Protein
- C. Vitamins C and A
- D. Complete protein
Correct Answer: C
Rationale: A vegetarian diet can provide adequate amounts of protein, fat, and even complete protein if well-balanced. However, certain essential nutrients like vitamins C and A are more commonly found in higher concentrations in animal-based products. Therefore, in a vegetarian diet, particularly if not carefully planned, there may be a potential lack of these specific vitamins. It is important for the nurse to educate the parents on alternative plant-based sources of vitamins C and A to ensure their child's nutritional requirements are met.
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is X linked recessive disorder :
- A. thalassemia
- B. hemophilia
- C. leukemia
- D. sickle anemia
Correct Answer: B
Rationale: Hemophilia is an X-linked recessive disorder where the genes responsible for blood clotting factors are located on the X chromosome. This disorder primarily affects males, as they have only one X chromosome. Females are carriers and can pass the gene on to their sons. Hemophilia results in prolonged bleeding episodes as the blood is unable to clot properly. Thalassemia, leukemia, and sickle cell anemia are not X-linked disorders. Digoxin is a medication used for heart conditions, not related to X-linked disorders.
A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate?
- A. "It appears your baby has a kidney infection"
- B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk"
- C. "The baby probably passed a small kidney stone"
- D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"
Correct Answer: D
Rationale: The most appropriate explanation to the newborn's mother is option D, "Some infants experience menstruation-like bleeding when hormones from the mother are not available." This condition is known as neonatal menstrual-like bleeding or pseudo-menstruation. During pregnancy, babies are exposed to the mother's hormones in the womb. After birth, when the hormonal influence from the mother decreases, some female infants may experience vaginal bleeding, which can be seen in their diapers. This type of bleeding is usually benign and resolves on its own without any intervention. It is not a cause for concern and does not indicate any serious health issue. The straw-colored urine with no offensive odor is a normal finding and further supports the explanation of neonatal menstrual-like bleeding in this case.
Which clinical manifestation would be seen in a child with chronic renal failure?
- A. Hypotension
- B. Massive hematuria
- C. Hypokalemia
- D. Unpleasant "uremic" breath odor
Correct Answer: D
Rationale: Chronic renal failure is characterized by the buildup of waste products and toxins in the blood due to kidney dysfunction. One common clinical manifestation in children with chronic renal failure is the development of an unpleasant "uremic" breath odor. This odor is often described as a fishy or ammonia-like smell and is a result of the accumulation of urea in the blood, which is normally filtered out by the kidneys. Other common clinical manifestations of chronic renal failure in children may include hypertension, fluid retention, electrolyte abnormalities (such as hyperkalemia rather than hypokalemia), anemia, growth failure, and bone abnormalities.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The symptoms described in the scenario, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, are indicative of an immediate hypersensitivity reaction, also known as a Type I hypersensitivity reaction. This type of reaction is triggered by the release of histamine and other inflammatory mediators from mast cells and basophils. Symptoms can range from mild to severe and can manifest rapidly after exposure to the allergen, in this case, the blood transfusion. Common manifestations include skin reactions (e.g., itching, urticaria), respiratory symptoms (e.g., chest pain, wheezing), cardiovascular changes (e.g., tachycardia, hypotension), and gastrointestinal symptoms (e.g., nausea, vomiting).
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended for diabetic foot care as it can increase the risk of burns and skin damage due to reduced sensitivity and circulation in the feet. Instead, it is advised to wash your feet in warm water, not hot, and to thoroughly dry them, especially in between the toes, to prevent fungal infections.