Nokea
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. "Never suction your tracheostomy; you might damage your trachea."
- B. ""You should not feel bad about the tracheostomy – you should be feel lucky to be alive."
- C. "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals."
- D. "Your tracheostomy will be cleaned each time you visit your doctor."
Correct Answer: C
Rationale: Option C, "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals," is the most appropriate instruction for a patient with a new tracheostomy. It is important to keep the tracheostomy site clean and free from any potential irritants or contaminants that could cause infection or complications. Powders, hair, and chemicals can lead to irritation or clogging of the tracheostomy tube, so it is crucial for the patient to be mindful of avoiding such pollutants near the tracheostomy site.
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Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
Which best describes acute glomerulonephritis?
- A. Occurs after a urinary tract infection
- B. Occurs after a streptococcal infection
- C. Associated with renal vascular disorders
- D. Associated with structural anomalies of genitourinary tract
Correct Answer: B
Rationale: Acute glomerulonephritis is commonly associated with a preceding streptococcal infection, particularly Group A beta-hemolytic streptococcal infection such as strep throat or impetigo. The infection triggers an abnormal immune response leading to inflammation of the glomeruli in the kidneys. This inflammation impairs the kidneys' ability to filter waste and excess fluids from the blood, resulting in symptoms such as hematuria (blood in urine), proteinuria (protein in urine), hypertension, and edema. Other causes such as renal vascular disorders, structural anomalies of the genitourinary tract, or urinary tract infections are not typically linked to acute glomerulonephritis.
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
- A. insulin.
- B. poatassium chloride.
- C. furosemide (Lasix)
- D. vasopressin (Pitressin).
Correct Answer: D
Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to conserve water, leading to excessive urination and extreme thirst. The main treatment for diabetes insipidus is the administration of vasopressin (also known as antidiuretic hormone or ADH). Vasopressin helps the kidneys retain water, reduce urine output, and stabilize the body's fluid balance. Therefore, in caring for a client with diabetes insipidus, the nurse should anticipate the administration of vasopressin to help manage the symptoms of excessive urination and dehydration.
Which of the following diets would the nurse include in the plan of care for a person with AIDS?
- A. A high-protein, high-calorie diet divided into six small meals.
- B. A low-fat, soft diet divided into 8 small meals.
- C. A high-carbohydrate, fat-restricted diet divided into 4 meals.
- D. A high-fat, high-calorie diet divided into 3 meals.
Correct Answer: A
Rationale: People with AIDS often experience weight loss and malnutrition due to the disease's impact on the immune system. A high-protein, high-calorie diet can help support the immune system and maintain or improve weight. Dividing the meals into six servings can help with better absorption of nutrients and provide a steady source of energy throughout the day. This type of diet can also help manage symptoms and side effects of the disease and its treatments, such as maintaining muscle mass, managing nausea, and supporting overall health.
The parent of a 7-year-old with continued bed-wetting at night says they've tried getting the child up at 11:30 p.m. Which is the best next step?
- A. There is a medication (DDAVP) that may help decrease urine volume.
- B. Be firm and show how much work is involved in changing sheets.
- C. Limit fluids in the evening and consider a reward system for dry nights.
- D. Bed-wetting alarms are available and effective.
Correct Answer: C
Rationale: Reducing evening fluids and using positive reinforcement (reward system) are effective and developmentally appropriate strategies.