Nokea
The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease?
- A. Edema
- B. Redness
- C. Pruritus
- D. Maceration
Correct Answer: C
Rationale: Scabies is a contagious skin infestation caused by the itch mite Sarcoptes scabiei. The primary clinical manifestation of scabies is intense itching, known as pruritus. The itching is often worse at night and can be severe, leading to scratching that can cause skin lesions. Edema (choice A) refers to swelling due to fluid retention and is not a primary clinical manifestation of scabies. Redness (choice B) may be present due to inflammation caused by the mites but is not the primary symptom. Maceration (choice D) is softening and breakdown of the skin due to prolonged moisture exposure and is not a typical presentation of scabies.
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Poor prognostic factors in Hodgkin lymphoma include all the following EXCEPT
- A. age of more than 15 year at the time of diagnosis
- B. stage IV disease
- C. manifested by positron emission tomography (PET) scan positivity
- D. poor response to therapy
Correct Answer: A
Rationale: Older age is generally considered a poor prognostic factor, but not necessarily worse than other listed options.
Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age?
- A. 1 month
- B. 3 to 4 months
- C. 6 to 8 months
- D. 12 months
Correct Answer: C
Rationale: Binocularity refers to the ability of both eyes to focus on the same object and create a single, three-dimensional image. In infants, binocularity typically develops between the ages of 6 to 8 months. Prior to this age, it is common for infants to show occasional misalignment or "crossed" eyes when focusing on an object. This is usually a normal part of the visual development process and tends to resolve as binocular vision strengthens with age. Therefore, it is considered normal for newborns to show occasional crossed eyes until binocularity develops around 6 to 8 months of age.
The nurse is caring for a patient on warfarin with an elevated INR level. Which of the ff. would be ordered as the antidote for warfarin?
- A. Vitamin K c.Calcium Chloride
- B. Vitamin B12
- C. Protamine Sulfate
Correct Answer: A
Rationale: Warfarin is an anticoagulant medication that works by inhibiting the production of certain clotting factors in the liver, thus prolonging the time it takes for blood to clot. An elevated INR level indicates that the blood is taking longer to clot than desired, potentially putting the patient at risk for bleeding. Vitamin K is the antidote for warfarin because it helps the liver produce these clotting factors, ultimately reversing the effects of warfarin and promoting normal blood clotting. Administering Vitamin K helps lower the INR level and reduce the risk of bleeding in patients on warfarin therapy. Therefore, in this scenario, Vitamin K would be the appropriate antidote to use for the patient with an elevated INR level.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
- A. Serum hepatitis
- B. Pulmonary edema
- C. Allergic response
- D. Hemolytic reaction Situation: Joel is a toddler who has classical hemophilia.
Correct Answer: D
Rationale: A hemolytic reaction is the most likely problem associated with blood transfusion. A hemolytic reaction occurs when the body's immune system attacks the transfused blood, leading to the destruction of red blood cells. This reaction can cause serious complications, including kidney damage, shock, and even death. It is crucial for healthcare providers to carefully match blood types and perform compatibility testing before administering a blood transfusion to minimize the risk of a hemolytic reaction. Serum hepatitis, pulmonary edema, and allergic responses are potential complications of blood transfusions, but hemolytic reactions pose the most immediate and severe threat to the patient's health.