Nokea
The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increasing intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: The correct answer is B: Ear infections. Parents of a child with a cleft palate should report ear infections immediately because children with cleft palate are at higher risk for developing ear infections due to issues with Eustachian tube function. Ear infections can lead to hearing loss if left untreated. Facial paralysis (A) is not directly related to cleft palate. Increasing ICP (C) is not typically associated with cleft palate. Drooling (D) is common in children with cleft palate and does not require immediate reporting unless there are other concerning symptoms present.
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Which is a constellation of physical and psychological symptoms beginning in the luteal phase of the menstrual cycle and followed by a symptom-free period?
- A. Endometriosis
- B. Abnormal uterine bleeding
- C. Premenstrual syndrome
- D. Depression
Correct Answer: C
Rationale: Rationale:
1. Premenstrual syndrome (PMS) occurs in the luteal phase due to hormonal changes.
2. PMS includes physical and psychological symptoms.
3. It is followed by a symptom-free period (during menstruation).
4. Endometriosis is a separate condition involving tissue growth outside the uterus.
5. Abnormal uterine bleeding refers to irregular bleeding patterns.
6. Depression is a mental health condition not specific to the menstrual cycle.
Summary:
PMS is the correct answer as it aligns with the timing, symptoms, and pattern described in the question. Endometriosis, abnormal uterine bleeding, and depression do not fully match the criteria provided.
The client receives zidovudine (Retrovir) for treatment of HIV infection. Which assessment data indicates an adverse reaction to the drug?
- A. Cough
- B. Enlarged lymph nodes
- C. Decreased WBC count
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Decreased WBC count. Zidovudine is known to cause bone marrow suppression which can lead to a decrease in white blood cell count. This is an adverse reaction as it increases the risk of infections.
A: Cough is not a common adverse reaction to zidovudine.
B: Enlarged lymph nodes are not directly associated with zidovudine adverse reactions.
D: Fever is a non-specific symptom and can occur due to various reasons, not specifically related to zidovudine.
Therefore, the most concerning and relevant assessment data indicating an adverse reaction to zidovudine is a decreased white blood cell count.
The nurse is reviewing the chart of a client who is complaining of heavy bleeding with her menstrual cycles. The nurse is aware that which of the following is a possible cause?
- A. Uterine fibroids
- B. Excessive exercise
- C. Normal finding in pregnancy
- D. Diet high in fat
Correct Answer: A
Rationale: The correct answer is A: Uterine fibroids. Uterine fibroids are noncancerous growths in the uterus that can lead to heavy menstrual bleeding. The nurse should consider this as a possible cause based on the client's symptoms.
Incorrect Choices:
B: Excessive exercise - While excessive exercise can sometimes affect menstrual cycles, it is not a common cause of heavy bleeding.
C: Normal finding in pregnancy - Heavy bleeding during menstrual cycles is not a normal finding in pregnancy.
D: Diet high in fat - While diet can impact overall health, a diet high in fat is not a direct cause of heavy menstrual bleeding.
Which best describes the signs and symptoms of trichomoniasis in women?
- A. Foul, fishy odor and thick clumpy white vaginal discharge
- B. Malodorous, frothy yellow-green vaginal discharge
- C. Dysuria and thin milky-white vaginal discharge
- D. Condition is asymptomatic in women
Correct Answer: B
Rationale: Rationale: Trichomoniasis is characterized by malodorous, frothy yellow-green vaginal discharge due to the presence of Trichomonas vaginalis parasite. This discharge is a hallmark sign of the infection. Other choices are incorrect because:
A: Foul, fishy odor and thick clumpy white discharge are more indicative of bacterial vaginosis or yeast infection.
C: Dysuria and thin milky-white discharge are more suggestive of a urinary tract infection.
D: Trichomoniasis can manifest with symptoms in women such as vaginal discharge, itching, and discomfort.
Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy?
- A. Cover the infant's head with a hat.
- B. Dress the infant lightly in a T-shirt.
- C. Keep the infant's eyes covered.
- D. Reposition the infant at least every 4 to 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Keep the infant's eyes covered. This is important during phototherapy to protect the infant's eyes from potential damage due to exposure to light. Direct light can harm the infant's developing eyes, so covering them is crucial.
Choice A: Cover the infant's head with a hat - This is not necessary for phototherapy as the focus should be on protecting the eyes, not the head.
Choice B: Dress the infant lightly in a T-shirt - While dressing the infant lightly is recommended, it is not as critical as protecting the eyes.
Choice D: Reposition the infant at least every 4 to 8 hours - Repositioning is important for preventing pressure ulcers but is not directly related to the safety of the eyes during phototherapy.