Nokea
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.
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A patient reports on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
- A. Give the antibiotic
- B. Do not give the antibiotic
- C. Give half of the dose
- D. Discontinue the antibiotic
Correct Answer: B
Rationale: In this scenario, the patient reports being "very sick" after taking erythromycin in the past, indicating a history of adverse reaction to the medication. Given this information, it would be most prudent to withhold the erythromycin to prevent a potential adverse reaction or worsening of the patient's condition. It is important for the nurse to always consider the patient's previous experiences and adverse reactions when administering medications to ensure patient safety.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to hyperventilation, leading to an increase in pH. In respiratory alkalosis, the body is expelling too much carbon dioxide, causing the blood to become more alkaline. The nurse's interpretation of the situation as respiratory alkalosis suggests that the patient may be breathing rapidly or deeply, resulting in the elimination of excess carbon dioxide and a shift towards alkalosis.
Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for hypocortisolism, also known as adrenal insufficiency. This is because the procedure involves removing the pituitary gland, which plays a critical role in regulating cortisol production by the adrenal glands. Without proper cortisol production, the client may develop symptoms such as weakness, fatigue, low blood pressure, weight loss, and nausea. Monitoring for signs of hypocortisolism is crucial for prompt detection and intervention to prevent adrenal crisis, which can be life-threatening. Hyperglycemia, hypoglycemia, and hypercalcemia are not typically direct concerns following a transsphenoidal hypophysectomy.
The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is most likely lacking in their particular diet?
- A. Fat
- B. Protein
- C. Vitamins C and A
- D. Complete protein
Correct Answer: C
Rationale: A vegetarian diet can provide adequate amounts of protein, fat, and even complete protein if well-balanced. However, certain essential nutrients like vitamins C and A are more commonly found in higher concentrations in animal-based products. Therefore, in a vegetarian diet, particularly if not carefully planned, there may be a potential lack of these specific vitamins. It is important for the nurse to educate the parents on alternative plant-based sources of vitamins C and A to ensure their child's nutritional requirements are met.
How does the nurse assess a child's capillary refill time?
- A. Inspecting the chest
- B. Auscultating the heart
- C. Palpating the apical pulse
- D. Palpating the skin to produce a slight blanching
Correct Answer: D
Rationale: Capillary refill time is a clinical assessment used to evaluate peripheral perfusion. To perform this assessment on a child, the nurse would gently press on the child's nail bed or skin, causing the area to momentarily blanch (turn white) as blood is temporarily forced out of the capillaries. Once pressure is released, the nurse observes and times how quickly the color returns to normal. A normal capillary refill time in a child is less than 2 seconds. This method helps the nurse determine if the child's peripheral circulation is adequate. Inspecting the chest (choice A), auscultating the heart (choice B), and palpating the apical pulse (choice C) are not appropriate methods for assessing capillary refill time.