Nokea
The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?
- A. Ask for detailed listing of symptoms.
- B. Ask adolescent, "Why did you come here today?"
- C. Use what adolescent says to determine, in correct medical terminology, what the problem is.
- D. Interview parent away from adolescent to determine chief complaint.
Correct Answer: B
Rationale: When determining the chief complaint for an adolescent during a health history, the best approach is to directly ask the adolescent, "Why did you come here today?" This allows the nurse to understand the reason for the visit from the adolescent's perspective and helps in identifying the primary concern or reason for seeking medical care. Adolescent patients should be encouraged to express their own concerns and symptoms in their own words, which can help in building trust and promoting open communication between the nurse and the patient. It is important to prioritize the adolescent's input in determining the chief complaint, as it relates to their own health and well-being.
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A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: Chronic respiratory acidosis is a condition where there is an excess of carbon dioxide (CO2) in the blood due to inadequate exhalation of CO2. This typically occurs as a result of hypoventilation, which is characterized by breathing at an abnormally slow rate or shallow depth. In patients with long-standing lung disease, the ability to effectively exchange gases in the lungs is compromised, leading to a buildup of CO2 in the bloodstream and subsequent respiratory acidosis. Hyperventilation, on the other hand, would result in a decrease in CO2 levels in the blood, while the loss of acid or base by the kidneys is related to metabolic acidosis or alkalosis, not respiratory acidosis. Therefore, in this case, the primary problem causing chronic respiratory acidosis is hypoventilation.
A client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis site for cancer cells?
- A. Liver
- B. Reproductive tract
- C. Colon
- D. White blood cells (WBCs)
Correct Answer: A
Rationale: The liver is one of the most common sites for metastasis of cancer cells. This is because the liver receives a high volume of blood flow, making it a common site for cancer cells to spread through the bloodstream. Additionally, the liver's function in filtering toxins and foreign substances from the blood makes it a favorable environment for cancer cells to establish secondary tumors. Monitoring the liver for metastasis is crucial in cancer diagnosis and management.
A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours after birth, the newborn begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. Which is important for the nurse to recognize?
- A. This is a normal finding.
- B. This is not significant unless cyanosis is present.
- C. Improvement should occur within 24 hours.
- D. Further evaluation is needed.
Correct Answer: D
Rationale: The presentation of a preterm newborn with difficulty breathing, grunting, tachypnea, and nasal flaring is concerning and should not be considered a normal finding. This could indicate respiratory distress, which is common in preterm infants due to immature lung development. It is important for the nurse to recognize these symptoms as they may signify a potential underlying respiratory issue that requires further evaluation and intervention. Prompt assessment and management are crucial in ensuring the best outcomes for the newborn. Therefore, further evaluation by the healthcare team is warranted in this situation to determine the cause of the respiratory distress and provide appropriate treatment.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. To relieve the cyanosis and dyspnea, the nurse should place the infant in the:
- A. Orthopneic position
- B. Knee-chest position
- C. Lateral Sims' position
- D. Semi-Fowler's position
Correct Answer: A
Rationale: The orthopneic position is the best position to relieve cyanosis and dyspnea in an infant with tetralogy of Fallot. This position involves sitting up and leaning forward, which helps improve lung expansion and oxygenation. Placing the infant in the orthopneic position will reduce the workload on the heart, improve oxygenation, and relieve symptoms of cyanosis and dyspnea associated with tetralogy of Fallot. It allows for better expansion of the lungs and improves ventilation-perfusion matching, thereby enhancing oxygen exchange and alleviating the cyanotic spell.