Nokea
The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?
- A. Normal
- B. Erythema
- C. Jaundice
- D. Ecchymosis
Correct Answer: C
Rationale: Jaundice is the yellow discoloration of the skin, sclera (white part of the eyes), soles of feet, and palms of hands that occurs due to elevated levels of bilirubin in the blood. Bilirubin is a yellow pigment produced during the breakdown of red blood cells and is normally processed by the liver and excreted in bile. When the liver is unable to process bilirubin effectively, it can accumulate in the blood and cause jaundice. Therefore, the nurse should document these findings as jaundice, which is a sign of liver dysfunction or other underlying health issues that need further assessment and management.
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Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: Acute respiratory distress syndrome (ARDS) is a serious condition that can lead to various complications, including renal failure. When a client is experiencing ARDS, the lungs become severely inflamed and filled with fluid, which can lead to decreased oxygen levels in the blood. This decrease in oxygen can place a significant strain on the kidneys, potentially resulting in renal failure. Therefore, it is crucial for nurses to monitor the client for signs and symptoms of renal failure, such as changes in urine output, fluid imbalance, electrolyte abnormalities, and altered mental status. Timely detection and management of renal complications in clients with ARDS are essential to prevent further deterioration of the client's condition.
Which is the causative agent of scarlet fever?
- A. Enteroviruses
- B. Corynebacterium organisms
- C. Scarlet fever virus
- D. Group A b-hemolytic streptococci (GABHS)
Correct Answer: D
Rationale: Scarlet fever is caused by Group Aß-hemolytic streptococci (GABHS), particularly Streptococcus pyogenes. This bacteria produces erythrogenic exotoxins that cause the characteristic rash seen in scarlet fever. These toxins also contribute to the other symptoms associated with scarlet fever, such as high fever, sore throat, and a red, bumpy tongue (strawberry tongue). Therefore, the correct causative agent of scarlet fever is Group Aß-hemolytic streptococci (GABHS).
Regarding physical growth of middle childhood (6-11 years), all are true EXCEPT
- A. 3-3.5 kg weight increment/yr
- B. 6-7 cm height increment/yr
- C. brain stops myelinization by 8 years
- D. risk for future obesity falls by 6 years
Correct Answer: D
Rationale: Risk for obesity does not necessarily fall by 6 years.
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
- A. Probenecid (Benemid)
- B. Cytarabine (ara-C, cystosine arabinoside [Cytosar-U])
- C. Thioguanine (6-thioguanine, 6-TG)
- D. Leucovorin (Citrovorum factor or folinic acid [wellcovirin])
Correct Answer: D
Rationale: Leucovorin, also known as folinic acid, is given concurrently with methotrexate therapy to protect normal cells from the toxic effects of methotrexate. Methotrexate is a folate antagonist that affects both cancer cells and normal cells. Leucovorin is a reduced form of folic acid that bypasses the enzyme targeted by methotrexate, allowing normal cells to continue using folate for DNA synthesis. This rescue therapy helps prevent or reduce the side effects of methotrexate, such as mucositis, myelosuppression, and other toxic effects on normal cells. It is important to administer leucovorin at the appropriate times following methotrexate administration to maximize its protective effect while maintaining the efficacy of the chemotherapy.
Which part of the body is supplied by nerves form the thoracic cord?
- A. Head
- B. Pelvis
- C. Trunk
- D. Coccyx
Correct Answer: C
Rationale: Nerves from the thoracic cord supply the trunk of the body. The thoracic spinal cord region is responsible for supplying nerves to the chest, abdomen, and back—the areas that make up the trunk of the body. Each level of the thoracic spinal cord is associated with specific nerves that innervate different areas of the trunk, including the intercostal muscles, abdominal muscles, and other structures. Therefore, the trunk is the part of the body supplied by nerves from the thoracic cord.