Nokea
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The nurse will assess a loss of ability in the area of balance. Balance is an essential component of the physical function that allows individuals to maintain an upright posture and stability during movement. A loss of balance can significantly impact a person's mobility, coordination, and safety. Nurses often assess balance as part of their evaluations to identify any impairments that may affect a patient's independence and daily activities.
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During starvation, the body slows metabolic processes and growth to minimize the need for nutrients. With the rapid reinstitution of feeding after starvation refeeding syndrome may occur. Of the following, the major changes that may occur with refeeding syndrome typically affect
- A. electrolytes
- B. serum proteins
- C. hormones
- D. liver enzymes
Correct Answer: A
Rationale: Refeeding syndrome primarily affects electrolytes, particularly phosphorus, potassium, and magnesium, which can become dangerously depleted due to rapid shifts in metabolism.
Nurse Hannah is administering a steroid to a child diagnosed with idiopathic thrombocytopenic purpura (ITP); which of the following should the nurse monitor?
- A. Infection
- B. Anemia
- C. Bleeding
- D. Bruising
Correct Answer: C
Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Steroids are often prescribed to help increase platelet production in patients with ITP. Therefore, the nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, gum bleeding, and other unusual bleeding manifestations. Monitoring for bleeding is crucial to assess the effectiveness of the steroid treatment and to prevent complications associated with ITP.
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.
In embryonic period, all are true EXCEPT
- A. formation of ectoderm by 8 days
- B. formation of mesoderm by 10 weeks
- C. formation of endoderm by 3 cm crown-rump length
- D. formation of human embryo is about 6 weeks
Correct Answer: D
Rationale: The formation of the human embryo is completed by 8 weeks, not 6 weeks.
A 3-day-old neonate has a large, soft, painless mass involving the head and neck region that mostly transilluminate; CT scan reveals a cystic mass involving the neck and intrathoracic mediastinum. The BEST modality for treatment of this neonate is
- A. surgical resection
- B. injection sclerosing agent
- C. laser therapy
- D. systemic interferon therapy
Correct Answer: A
Rationale: Surgical resection is the definitive treatment for cystic hygroma.