Nokea
The nurse notes small, pimple-like pustules all over the newborn's body. When charting the integumentary assessment of this newborn, which normal finding does the nurse note?
- A. Strawberry hemangiomas
- B. Port-wine stain
- C. Erythema toxicum
- D. Telangiectatic nevi simplex
Correct Answer: C
Rationale: Small, pimple-like pustules on a newborn's body suggest erythema toxicum (C), a benign, self-limiting rash common in the first week of life, often with erythematous macules and pustules. Strawberry hemangiomas (A) are vascular growths, not pustular. Port-wine stains (B) are flat, purple birthmarks. Telangiectatic nevi simplex (D) are salmon-colored patches, not pustules. C is correct. Rationale: Erythema toxicum affects up to 70% of newborns, caused by an immune response, resolving without treatment, distinct from vascular or permanent lesions, aligning with normal neonatal skin findings.
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The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by
- A. Vasoconstriction
- B. Vasodilatation
- C. Decreases force of contractility
- D. Decreases cardiac output
Correct Answer: B
Rationale: The coronary vessels are unique because they respond to sympathetic stimulation with vasodilatation, unlike most other blood vessels which constrict. Sympathetic stimulation activates the fight-or-flight response, increasing heart rate and oxygen demand. To meet this demand, the coronary arteries dilate to supply more blood to the heart muscle. Vasoconstriction (A) is incorrect as it would reduce blood flow, countering the heart's needs during stress. Decreases in force of contractility (C) or cardiac output (D) are unrelated to the vascular response and pertain more to myocardial function, not the coronary vessels' behavior. This vasodilatation is mediated by beta-adrenergic receptors, ensuring adequate perfusion during heightened activity, making B the correct choice.
One of the expectations is for nurses to join professional association primarily because of
- A. Promotes advancement and professional growth among its members
- B. Works for raising funds for nurse's benefit
- C. Facilitate and establishes acquaintances
- D. Assist them and securing jobs abroad
Correct Answer: A
Rationale: Professional associations, like the PNA, promote growth e.g., offering training, certifications enhancing skills and standards. Fundraising, networking, or job placement are secondary. This advancement focus, rooted in nursing's professionalization, ensures competence and leadership, critical for career development and patient care quality.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.