Nokea
The nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve. What should the nurse include in the plan of care? Select all that apply.
- A. Assistance with ambulation
- B. Regular hearing tests
- C. Monitoring for nausea
- D. Vision assessments
Correct Answer: A
Rationale: Damage to the vestibular area affects balance and may cause nausea. Therefore, the nurse should include assistance with ambulation in the care plan to help the client maintain stability while walking. Regular hearing tests (choice B) are not directly related to damage in the vestibular area of the vestibulocochlear nerve. While nausea (choice C) may occur due to vestibular damage, monitoring for it alone is not as essential as providing assistance with ambulation. Vision assessments (choice D) are important for assessing visual function but are not the priority when dealing with vestibular issues.
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A patient taking hormonal contraceptives will soon turn 35 years of age. She is moderately obese and has smoked for 15 years. Which of the following is most important?
- A. Begin an exercise regimen.
- B. Begin smoking cessation.
- C. Begin daily aspirin therapy.
- D. Begin taking a loop diuretic to aid weight loss.
Correct Answer: B
Rationale: The most important action for a patient taking hormonal contraceptives, who is nearing 35 years of age, moderately obese, and has a history of smoking for 15 years, is to begin smoking cessation. Women over 35, especially smokers, are at an increased risk of blood clots and cardiovascular issues when using hormonal contraceptives. Smoking cessation is crucial to reduce this risk. Beginning an exercise regimen may be beneficial for overall health but is not as critical as stopping smoking in this scenario. Daily aspirin therapy or taking a loop diuretic are not indicated in this situation and may not address the primary risk associated with hormonal contraceptives and smoking.
Which scenario would be an example of a child born with congenital insensitivity to pain?
- A. A child who does not cry when injured and fails to respond to painful stimuli.
- B. A child who cries excessively and has a heightened response to pain.
- C. A child who experiences pain but has difficulty expressing it.
- D. A child who is sensitive to minor stimuli but has a delayed response to severe pain.
Correct Answer: A
Rationale: The correct scenario depicting a child with congenital insensitivity to pain is when the child does not cry when injured and fails to respond to painful stimuli. This condition is characterized by the inability to feel and react to pain, resulting in a lack of typical responses such as crying or withdrawal when hurt. Choice B is incorrect as it describes a child with heightened pain sensitivity, opposite to the insensitivity seen in the condition. Choice C is incorrect as it suggests the child feels pain but struggles to communicate it, which is not the case with congenital insensitivity to pain. Choice D is incorrect as it describes a child who is sensitive to minor stimuli and has delayed responses to severe pain, which is not indicative of congenital insensitivity to pain.
Which of the following characteristics is common in both malignant and benign tumors?
- A. Uncontrolled cell growth
- B. Rapid growth
- C. Metastasis
- D. Invasion of surrounding tissue
Correct Answer: A
Rationale: The correct answer is A: Uncontrolled cell growth. This characteristic is common to both malignant and benign tumors. Benign tumors are non-cancerous growths that do not invade nearby tissue or spread to other parts of the body. Therefore, choices B, C, and D are incorrect. Rapid growth, metastasis, and invasion of surrounding tissue are characteristics typically associated with malignant tumors.
A patient being treated for tuberculosis is determined to be drug resistant. Which of the following medications will the patient be resistant to in the treatment of tuberculosis?
- A. Isoniazid (INH) and rifampin
- B. Carbamazepine (Tegretol) and phenytoin (Dilantin)
- C. Dextroamphetamine (Dexedrine) and doxapram (Dopram)
- D. Propranolol (Inderal) and sotalol (Betapace)
Correct Answer: A
Rationale: In the treatment of tuberculosis, drug resistance commonly develops against medications like Isoniazid (INH) and rifampin. These two drugs are key components of the standard anti-tuberculosis treatment regimen. Choices B, C, and D are unrelated medications that are not used in the treatment of tuberculosis. Carbamazepine and phenytoin are anticonvulsants, dextroamphetamine is a stimulant, and propranolol and sotalol are used for cardiovascular conditions.
The nurse is preparing to administer a vaccine to a newborn. Before administering the vaccine, the nurse should
- A. warm the vaccine to room temperature.
- B. gently cleanse the chosen injection site.
- C. check the infant's temperature.
- D. administer the full dose at a single injection site.
Correct Answer: C
Rationale: Before administering a vaccine to a newborn, it is essential for the nurse to check the infant's temperature. This is important to ensure that the newborn does not have a fever, which could indicate an underlying infection or illness. Warming the vaccine to room temperature is not necessary and could be harmful. Vigorously massaging the injection site is not recommended as it can cause discomfort and tissue damage. Dividing the dose for administration to three injection sites is not standard practice for vaccine administration to a newborn.